[
    {
        "Introduction": "hello and welcome to chapter 29 head and spine injuries of the emergency care and transportation of the sick and injured 12th edition after you complete this\nthe nervous system is a complex network of nerve cells that enables all parts of the body to function the nervous system includes the brain spinal cord nerve fibers and nerves the nervous system is well protected the brain is protected by the skull the spinal cord is protected by the bony spinal canal and despite its this protection though serious injuries can damage the nervous system",
        "National EMS Education Standard Competencies": "chapter and the related coursework you will understand how to manage trauma-related issues of the head and spine you will learn how to recognize life threats associated with these injuries as well as the need for immediate spinal stabilization and potentially airway and breathing support the curriculum includes details anatomy and physiology of the nervous system and the pathophysiology assessment and management of traumatic brain and spinal cord injuries this chapter provides details about traumatic brain injury including initial mechanism of injury and primary versus secondary injury transport considerations are discussed with a focus on potential deterioration this chapter is skills intensive with detail on bandaging traumatic airway control in line stabilization placement of a cervical collar immobilization of a lying patient sitting or standing and helmet removal okay so let's get into it",
        "Anatomy and Physiology": "so first let's talk about the anatomy and physiology the nervous system is divided into two on atomic parts okay so you have the central nervous system and then the peripheral nervous system the figure on this slide shows the two components of the nervous system the central and the peripheral so let's talk about the central nervous system first it includes the brain and spinal cord the brain controls the body and is the center of consciousness the brain is divided into three major areas the cerebrum cerebellum and brainstem the figure shows the parts of the brain the cerebrum co controls a wide variety of activities including most voluntary motor function and conscious thought contains about 75 of the brain's total volume it's divided into two hemispheres and four lobes the cerebellum coordinates violence and body movements the brain stem controls most functions necessary for life including cardiac and respiratory systems and nerve function transmissions it's the best protected part of the central nervous system the spinal cord is mostly made up of fibers that extend from the brain's nerve cells carries messages between the brain and the body via the gray and white matter of the spinal cord and then you have protective coverings the brain and spinal cord are covered with thick bony structures the central nervous system is further protected by the meninges which are three distinct layers of tissues that suspend the brain and the spinal cord within the skull and the spinal canal outer layer the dura mater is a tough fibrous layer that forms a sac to contain the central nervous system the inner two layers are called the arachnoid mater and the pia mater and they contain the blood vessels that nourish the brain and spinal cord the figure on this slide shows the layers of the protective covering surrounding the brain cerebral spinal fluid or csf is produced in a chamber inside the brain this is called the third ventricle csf primarily acts as a shock absorber when an injury does penetrate in all the protective layers clear watery csf may leak from the nose ears or an open skull fracture so let's talk about the peripheral nervous system now you have 31 pairs of spinal nerves they conduct impulses from the skin and other organs to the spinal cord and they conduct motor impulses from the spinal cord to the muscles the figure shows the major muscles or major nerves of the peripheral nervous system you also have 12 pairs of cranial nerves they transport information directly to or from the brain they perform special functions in the head and face including sight smell taste hearing and facial expressions there are two major types of peripheral nerves first you have the sensory nerves and they carry only one type of information and that's from the body to the brain via the spinal cord then you have motor nerves and motor nerves carry information from the central nervous system to the muscles the connecting nerves are found only in the brain and spinal cord and they connect the sensory and motor nerves with short fibers this allows the exchange of simple messages how the nervous system works the nervous system controls virtually all of the body functions including reflex activities voluntary activities and involuntary activities the connecting nerve in the spinal cord form a reflex arch a sensory nerve in this arch detects an irritating stimulus it bypasses the brain and sends the message directly to the motor nerve causing a response this figure shows that reflex arch okay so then we have the somatic or voluntary nervous system and it handles voluntary activities the autonomic which is the involuntary nervous system handles the body's functions that occur without conscious effort it's divided into two sections you have the sympathetic nervous system and the parasympathetic nervous system when confronted with threatening situations the sympathetic nervous system reacts to the stress with the fight or flight response the parasympathetic nervous system has the opposite effect on the body causing blood vessels to dilate slows heart rate and relaxes muscle sphincters the two divisions of the autonomic nervous system tend to balance each other so that the basic body functions remain stable and effective this is called homeostasis",
        "Skeletal System": "all right so let's talk about the skeletal system uh the skeletal system of course is the first is a skull and it's composed of two groups of bones the cranial and the facial bones the brain connects to the spinal cord through a large opening at the base of the skull called the form magnum four major bones make up the cranium the occipital the temporal the parental and the frontal the face is composed of 14 bones you have the maxilla the zagma the mandible nasal and frontal bones in the spinal cord that's the body's central supporting structure it has 33 vertebrae and they are divided into five sections you have the cervical thoracic lumbar sacral and cocksicle the figure on this shows the five sections of the spinal cord the front part of each vertebrae consists of a round solid block of bone and it's called the vertebral body the back forms the bony arch the series of arches form a tunnel called the spinal canal which encompasses and protects the spinal cord the vertebra are connected by ligaments and separated by cushions these are intervertebral discs so let's talk about head injuries a head injury is a traumatic insult to the head that may result in injury to soft tissue bony structures or the brain head injuries account for more than half of all traumatic deaths fatal injuries invariably involve the brain be alert to the fact that the patient may have sustained additional trauma there are generally two types of head injuries and there's the closed head injury and the open head injury closed",
        "Head Injuries": "head injuries are those in which the brain has been injured but there is no opening into the brain an open head injury is one in which the opening from the brain to the outside world exists often caused by penetrating trauma brain tissue may be exposed all right so let's talk about falls and motor vehicle crashes and those are the most common mechanism of injury common mechanisms of injury include assaults and sports related incidents the table on the slide shows the general signs and symptoms of a head injury",
        "Scalp Lacerations": "okay so let's talk about scalp lacerations and they can be minor or serious even small lacerations can quickly lead to significant blood loss especially in children in patients with multiple injuries bleeding from the scalp or facial aspirations may contribute to hypovolemia and then their skull fractures so a significant force applied to the head may cause a skull fracture it may be open or closed depending on whether there is underlying laceration of the scalp injuries or bullets or other penetrating weapons frequently result in fracture of the skull so let's talk about the signs and symptoms of the skull fracture and the patient's head could be appeared deformed you could see a visible crack in the skull you could see echomosis that develops under the eyes and these are called raccoon eyes or you could see echomosis that developed behind one ear or over the mastoid process and this is a battle sign and these figures show echomosis under the eyes and then behind the ear these are both signs of a skull fracture linear skull fractures they account for about 80 of all fractures to the skull radiographs or x-rays are required to diagnose a linear skull fracture because there are often no physical signs of such deformity then there are depressed skull fractures and they result in a high energy direct trauma to the head with a blunt object the frontal and parabola bones of the skull are the most susceptible and bony fragments may be driven into the brain resulting in an injury patients often present with signs of a neurologic injury such as loss of consciousness then you have the basilar skull fractures and those are associated with high energy trauma but usually occur following diffuse impact to the head these injuries generally result from extension of a linear fracture to the base of the skull and are usually diagnosed with the ct of the head signs of a basilar skull fracture include central cerebral spinal fluid draining from the ears raccoon eyes or battle signs and then you have open skull fractures and these are often associated with trauma to multiple body systems brain tissue may be exposed to the environment which significantly increases the risk of a bacterial infection and they have a very high mortality rate",
        "Traumatic Brain Injuries": "next we're going to talk about traumatic brain injuries and these are defined by the national head injury foundation as a traumatic insult to the brain capable of producing physical intellectual emotional social and vocational changes they're classified by two broad categories primary injury which is the direct injury or the secondary is an indirect injury primary injuries result um from the impact to the brain and then secondary injuries increase the severity of the primary injury so the secondary injury increases the severity and it could be caused by cerebral edema intracranial hemorrhage increased intracranial pressure or cerebral ischemia or infection hypoxia and hypotension are the most common causes of the secondary brain injury and will increase death and disability significantly in patients with a head injury secondary injuries may occur anywhere from a few minutes to several days following the initial head injury\nit can result from blunt or penetrating trauma coup contra coup injury the initial impact injuries the front part of the brain the head falling back against the head rest then injures the rear part of the brain so that's a coup contra coup injury cerebral edema may not develop until several hours following the initial injury low blood oxygen levels aggravate cerebral edema and monitor the patient for any seizure activity with any head injury what we're worried about is of course the injury but also the intracranial pressure and it accumulations of blood within the skull or swelling of the brain can rapidly lead to an increase icp which is intracranial pressure increase endocrine pressure increased icp squeezes the brain against the bony prominences within the cranium signs of increased icp include abnormal respiratory patterns such as a toxic and chain stokes breathing pattern okay decrease pulse rate headache nausea vomiting decrease alertness bradycardia sluggish or non-reactive pupils to cerebral posturing and increased or widened blood pressures there's also a thing called cushing's reflex and this is the symptom it's a triad of increased systolic blood pressure decreased pulse rate and irregular respirations intracranial hemorrhage so that's bleeding inside the skull that usually increases the in icp bleeding can occur between the skull and the dura mater beneath the dura mater but outside the brain or within the tissues of the brain itself so now let's talk about bleeding in the brain okay so an epidural hematoma that's accumulation of the blood between the skull and the dura mater nearly always the result of a blow to the head that produces a linear fracture of a thin of the thin temporal bone the middle artery running along a groove in the temporal bone so the arterial bleeding into the epidural space will result in rapidly progressing symptoms often the patient loses consciousness immediately following the injury this is often followed by a brief period of consciousness and it's called the lucid interval after which the patient lapses back into unconsciousness the pupil on the side of the hematoma becomes fixed and dilated and death will follow very rapidly without surgery to evacuate the hematoma now we're going to talk about the subdural hematomas and this is an accumulation of blood beneath the dura mata but outside the brain usually occurs after falls or injuries involving strong deceleration forces more common than epidural hematomas and may or may not be associated with a skull fracture it's associated with a venous bleed so the signs typically develop more gradually than with the epidural hematoma okay the patient often experiences a fluctuating level of consciousness or surge speech any patient with a suspected subdural hematoma needs to be evaluated by a physician and then you have an intracerebral hematoma and this involves bleeding within the brain itself it can occur following a penetrating injury to the head or because of a rapid deceleration forces many small deep intracerebral hemorrhages are associated with other brain injuries the progression of increased icp depends on the presence of other brain injuries the region of the brain and which is involved in the size of the hemorrhage intracerebral hematomas have a high mortality rate even if the hematoma is surgically evacuated and then you have subarachnoid hemorrhages and this is bleeding and it often occurs in the subarachnoid space where the cerebral spinal fluid circulates results in bloody csf and signs of a meningeal irritation such as neck rigidity or headache common causes include trauma or rupture of an aneurysm patients report a sudden severe headache as bleeding increases the patient will experience signs and symptoms of an increased icp a sudden severe subarachnoid hematoma usually results in death survivors often have permanent neurologic impairment",
        "Concussion": "then you can have concussions and that's a blow to the head or face and it may cause a concussion to the brain classified by mild traumatic brain injury it is a closed injury with a temporary loss of or alteration of the part of the brain's ability to function without demonstratable physical damage to the brain approximately 90 percent of patients who sustained a concussion do not experience any loss of consciousness a patient with a concussion may be confused or have amnesia um there are two different types there's retrograde amnesia and that's the ability to remember everything but the events leading up to the injury and then there's anterior grade amnesia and that's the ability to remember the events of the injury usually a concussion lasts only a short time so ask about symptoms of a concussion such as dizziness weakness visual changes or changes in the mood in any patient who has sustained an injury to the head additional signs and symptoms include nausea vomiting ringing in the ear slurred speech and the ability to focus assume that a patient with signs or symptoms of a concussion has a more serious injury until proven otherwise by a ct scan at the hospital or evaluation by the physician",
        "Contusion": "and then there's a contusion so contusion is bruising of the bone tissue which is results from the blunt trauma a contusion is far more serious than a concussion it involves physical injury to the brain tissue and may produce long-lasting and even permanent damage patients who have sustained a brain contusion may exhibit all of the signs of a brain injury",
        "Other Brain Injuries": "and then there's other brain injuries so brain injuries can also arise from medical conditions such as blood clots or hemorrhages problems with blood vessels high blood pressure and or other problems may cause spontaneous bleeding in the brain the signs and symptoms of a non-traumatic injury are often the same as those of a traumatic brain injury",
        "Spine Injuries": "okay so let's move on to the spine injuries the cervical thoracic and lumbar portions of the spine can be injured in a variety of ways you can have compression injuries and that can result from a fall regardless of whether the patient landed on his or her feet or experience a direct blow to the crown of the skull coccyx or top of the head forces that compress the spine vertebrae body can cause herniation of the disc subsequently compression on the spinal cord and nerve roots and fragmentation into the spinal canal motor vehicle crashes or other types of trauma can over extend or hyperflex the cervical spine and damage the ligaments and joints rotation flexion injuries of the spine result from rapid acceleration forces any unnatural motion can result in a fracture or a neurological deficit when the spine is pulled along its length so that's hyper extension it can cause fractures in the spine as well as ligament and muscle injuries when the bone of the spine are altered from traumatic forces they can fracture or move out of place permanent damage may occur common findings include pain and tenderness on palpation if you suspect these types of injuries take extra precautions when stabilizing the spine",
        "Patient Assessment": "all right so let's get into the patient assessment portion of this chapter and always we're gonna um suspect a spinal um possible head or spinal cord injury anytime you encounter any of the following mechanisms of injury okay so when we have a motor vehicle collision and especially those involving motorcycles snowmobiles and all-terrain vehicles also pedestrian or motor vehicle collision where falls greater than 20 feet or less than 10 feet for pediatric blunt trauma penetrating trauma to the head back torso rapid deceleration injuries hangings axial loading injuries or diving accidents",
        "Scene Size-up": "okay so scene size up make sure you have the scene safe evaluate every scene for hazards to your health and the health of your team or bystanders be prepared with appropriate standard precautions before you approach the patient in a motor vehicle crash and call for advanced life support to there as soon as possible so you have your mechanisms of injuries or nature of illness usually we're going to looking for the mechanism of injury so consider how the mechanism of injury produce the injuries expected",
        "Primary Assessment": "then you're going to do your primary assessment you want to focus on identifying and managing life threatening concerns the threats to circulation airway breathing are considered life-threatening and must be treated immediately reduction of on scene time and recognition of critical patients increase the patient's chances for survival or a reduction in the amount of irreversible damage next we're going to talk about spinal immobilization concerns so you need to be aware that any unnecessary movement of the patient can cause additional injuries begin by assessing the scene to determine the risk of injury then form a general impression of your patient based on his or her level of consciousness and chief complaint if the patient is absolutely clear in his or her thinking and does not have any neurological deficits spinal pain or tenderness evidence of intoxication or other illness or injuries that may mask a spinal injury you may consider not placing the patient in spinal restriction the backboard not so rigid and often places the patient in an autonomous atomically incorrect position for a long period of time circulation to the areas of the skin may be compromised and some patients could experience respiratory compromise because they're laying flat and their stomach is pushing on their diaphragm so try to minimize the amount of time a patient is on a backboard you want to apply a cervical collar as soon as you have assessed the airway and breathing and provided necessary treatments once the cervical collar is on do not move it unless it causes a problem with maintaining the airway or the patient so some sign of increasing icp if the device needs to be removed maintain manual stabilization of the cervical spine until it can be replaced so assessing for signs and symptoms of a head injury begin by asking the responsive patient the following questions ask them what happens where does it hurt does your neck or back hurt can you move your hands and feet did you hit your head confused or slurred speech repetitive questionings or amnesia in responsive patients are good indications of a head injury in the setting of trauma resume or assume your patient has a head injury until your assessment proves otherwise the decreased blood glucose levels may mimic these symptoms however\npatients with a decreased level of responsiveness should be considered to have a spinal cord injury based on their chief complaint all right so then the a b and c if the spinal injury is suspected you need to open the and assess the airway it's very important manually holding the patient's head still while you will assess the airway use the jaw thrust maneuver to open the airway if the jaw thrust maneuver is ineffective it is acceptable to use the chin the hell tilt chin lift maneuver as the last result vomiting may occur in a patient with a head injury irregular breathing such as shine stokes respirations may result from that increased icp you want to administer high flow oxygen and it's indicated for patients with a head and spinal injuries pulse ox values should not fall below 90 and ideally should be 95 or higher hyperventilation which is ventilating too fast or with too much force use only when capnography is available to ensure an end tidal co2 between 30 to 35. pulse that is too slow in the setting of a hinge injury can indicate a serious condition in your patient a single episode of hypoperfusion in a patient with a head injury can lead to a significant brain damage and even death so assess for signs and symptoms of shock and treat appropriately also control bleeding so the manner of transport is important with these trauma patients several transport considerations should be kept in the mind for patients with a head trauma patients with impaired airways open head wounds or normal vital signs or patients who do not respond to painful stimuli may need to be rapidly extricated from the motor vehicle and transported ensuring a patient's airway and providing high flow oxygen is paramount there is probably probability of vomiting and seizures so suction should be readily available a head trauma patient may deteriorate rapidly and require air medical transport in supine patients the head should be elevated 30 degrees if possible to help with icp remember to maintain immobilization of the spine",
        "History Taking": "investigate the chief complaint for your history taking so obtain a medical history and be alert for injury-specific signs and symptoms as well as any pertinent negatives if the patient is not responsive obtain attempt to obtain a history from other sources such as friends family members medical identification jewelry and cards and wallets make every attempt to obtain sample history for your patient and then there's the secondary assessment the ability to walk move extremities or feel sensations as well as the absence of pain does not necessarily rule out a spinal cord injury instruct the patient to keep still and not to move the head or neck when you do your physical exam you may you want it to be systematic from head to toe full body scan or systematic assessment to focus on a certain area or region of body so if time perform a secondary assessment while you're in route and then obtain a complete set of vitals vital signs are essential in addition to hands-on assessment you should be using monitoring vices to qualify uh quantify your patient's oxygen and circulatory status you want to maintain end tidal between 30 and 40 35 and 40 and an spo2 above 94. when you do your physical exam the considerations you want to use that decap btls exam to examine the head chest abdomen extremities and back check perfusion motor function and sensation and all extremities prior to moving the patient a decreased level of consciousness is the most reliable sign of head injury determine whether there is decreased movement or numbness and tingling in the extremities also look for blood or cerebral spinal fluid leaking from the ears mouth or nose or for bruising around the eyes or behind the ears assess pupil size and reaction to light and continue to monitor the pupils do not probe open scalp lacerations with your glove finger because this may push bone fragments into the brain and do not remove an impaled object from an open head injury next is your neurologic examination perform on a baseline assessment using the glass glaucoma score if your jurisdiction uses the revised trauma score then find findings from the glass calculator will be made using the revised trauma score record levels of consciousness that fluctuate or deteriorate the table on this slide shows the categories of the glass glaucoma score all right and then we're going to do the spine exam so inspect for decap btls and check for the extremities for circulations if there is impairment note the level pain or tenderness when you palpate is a warning sign that the spine injury may exist other signs and symptoms include an obvious deformity numbness weakness or tingling of the extremities and soft tissue emergencies in the spinal region obvious injuries to the head or neck may indicate injury to the cervical spine",
        "Reassessment": "and then the reassessment so repeat the primary assessment reassess signs and symptoms in the chief complaint and recheck the patient's interventions the patient's condition should be reassessed at least every five minutes all right and then the interventions so compare baseline vital signs with repeated vital signs rapid deterioration of neurologic signs following a head injury is a sign of an expanding intracranial hematoma or rapidly progressing brain swelling if csf is present cover the wound with a sterile gauze to prevent further contamination but do not bandage it tightly your protocol should include and administration of high flow 2 and the application of a cervical collar if indicated as part of a spinal immobilization reassessment should take place as the patient is transported to an appropriate trauma facility next we're going to talk about the communication and documentation so provide complete and detailed information to that destination facility hospitals may be better prepared for seriously injured patients with a more advanced warning and a description of the most serious problems found during your assessment more seriously injured patients should be documented and you should document their vital signs every five minutes more stable patients you can document them every 15 minutes you may be requested to testify as a witness so be sure to properly document so let's talk about emergency care for these head injuries",
        "Emergency Medical Care of Head Injuries": "there are three general principles and they are designed to protect and maintain the critical functions of this central nervous system you need to establish an adequate airway control bleeding and provide adequate circulation to maintain cerebral perfusion you want to assess the patient's baseline level of consciousness and continuously monitor that so when it comes to mandatory manage managing the airway the most important step is establishing and maintaining that adequate airway once the airway is open maintain the head and cervical spine in a neutral inline position until you have placed a cervical collar and have secured the patient on the backboard figure shows how to stabilize and maintain the head and cervical spine in a neutral inline position and apply a cervical collar\nremove any foreign body secretions or vomit from the airway and once you have cleared the airway check ventilation give supplemental oxygen to any patient with a suspected head injury particularly anyone who is having trouble breathing use a bvm to assist ventilations if the patient is breathing too slow or too shallow and placement of the airway device may be necessary to maintain airway patency consider calling for als if the patient's airway is compromised and then you have the c so you must begin cpr if the patient is in cardiac arrest active blood loss um can aggrava aggravate have hypoxia bleeding inside the skull may cause increased icp to rise to life-threatening levels you can almost always control bleeding from the scalp laceration by applying a direct pressure over the wound if you suspect a skull fracture do not apply excessive pressure to that wound if the dressing becomes soaked do not remove it just place the second dressing over the first and then there's shock so usually it's a result of hypovolemia caused by bleeding from other injuries transported immediately to the trauma center all right so let's talk about cushing's triad remember that's from increased intracranial pressure and basically it's increased blood pressure and that's hypertension decreased heart rate bradycardia and increa irregular respirations okay so if this process is allowed to continue it is fatal manage shock administer oxygen and ventilate as necessary but avoid hyperventilation so we just talked about managing head injuries now let's talk about managing spinal injuries remember to follow your standard precautions maintain the patient's airway while keeping the spine in the proper position you want to assess respirations and give supplemental oxygen if needed manually manage the airway so you want to do that jaw thrust maneuver to open the airway consider inserting an op have a suction unit available and provide supplemental oxygen if needed",
        "Emergency Medical Care of Spinal Injuries": "and so of course the figure on this slide shows how to perform that jaw thrust maneuver when it comes to spinal mobilization restriction with the cervical spine or of the cervical spine you want to mobilize the head and trunk so that the bone fragments do not cause further damage even small movements can cause significant injury to that spinal cord you want to follow the steps in skill drill 29-1 never force the head into a neutral position do not move the head any further if the patient reports any of the following symptoms the patient has muscle spasms increased pain numbness tingling or weakness in the arms or legs compromised airway or ventilations and these situations stabilize the patient in his or her current position then there's cervical collars so provide prime preliminary partial support that's what they provide it should be applied to every patient who has a possible spinal injury based on the mechanism of injury history or signs and symptoms and to be affected a rigid cervical collar must be the correct size for that patient follow the skills drills 29-2 and once the patient's head and neck have been manually stabilized assess the pulse motor functions and sensations in all extremities then assess the spinal cord area and neck maintain manual support until the patient has been fully secured to the backboard or vacuum mattress okay and then preparation for transport so with supine patients we're going to secure the patient to the long backboard other procedures to move the patient from the ground to the backboard is a fur four person log roll you may also slide the patient onto the backboard or bathroom vacuum mattress to secure patient to the backboard follow the steps in skill drill 29-3 the vacuum mattress so an alternative to that long backboard it molds to the specific contours of the body's reducing pressure point tenderness and therefore providing better comfort it also provides thermal insulation it's excellent for the elderly or a patient with an abnormal curvature of the spine the drawback is of this device is its thickness requiring careful patient movement to maintain that c-spine it can't be used for patients who weigh more than 350 pounds and it can be used on the spine sitting or standing patient so patients can be moved onto the vacuum mattress with a scoop stretcher or a log roll follow the steps in skill drill 29-4 sitting patients use a short board or other spine spinal extrication device to restrict movement of that cervical and thoracic spine then secure the short backboard to the long backboard expectations to this rule include situations in which you have a patient who is in danger and you need to gain immediate access to other patients or the patient's injuries justify our urgent removal in all of their cases follow the steps and skill to 29-5 all right so then standing patience a patient who's already standing and walking should be able to sit down gently and be transferred to the position in which the spine motion restriction can be maintained it's a mechanism and injury and clinical indications suggest spinal injury or the patient's ability to protect his or her spine establish spinal motion restriction clinical indications may include spinal tenderness or pain and alter altered level of consciousness neurologic deficits obvious anatomic deformity to the spine or high energy trauma in a patient who's intoxicated from drugs alcohol or distracting injury so during your assessment pain in the spine may be missed because of shock or because the patient's attention is directed to more painful areas because any manipulation of the unstable cervical spine may cause permanent damage to the spinal cord you must assume the presence of a spinal injury and all patients who have sustained a head injury use manual inline stabilization or cervical collar and long backboard this shows a short backboard and it's the most common short bag there backboard they are vest types and they have rigid short boards as well it's designed to mobilize and restrict movement of the head neck and torso and it's used to immobilize non-critical patients who are found in a seated position and have possible spinal injuries then you have the long backboards this is to provide full body stabilization and motion restriction to the head neck torso or pelvis or extremities it's used to immobilize patients who are found in any position sometimes in conjunction with short boards all right let's talk about helmet removal next so a helmet that fits well prevents that",
        "Helmet Removal": "patient's head from moving and should be left on providing there's no impending airway or breathing problems and it does not interfere with assessment and treatment of airway and ventilation problems you can properly immobilize the spine you need to remove that helmet though if it's a full face helmet if it makes assessing or managing airway problems difficult and removal of the face guard to improve airway access is not possible or if it prevents you from properly immobilizing the spine also if it allows excessive head movement or patient in cardiac arrest you need to remove it so the preferred method when you're removing a helmet should always be at least two people technique for removal depends on the actual helmet to be worn you and your partner should not move at the same time you should first consult the medical control about your decision to remove that helmet follow the steps and still skill drill 29-6 so an alternate method the disadvantage of this method is to allow the helmet to be removed with the application of less force thereby reducing the likelihood of motion occurring in the neck the disadvantage is that it is slightly more time consuming steps for the alternate method include remove the chin strap remove the face mask pop the jaw pads out of place place your finger inside the helmet during removal of the helmet the person on the side of the patient controls the head by holding the jaw with one hand and the occipit with the other insert padding behind the exhibit to prevent neck extension the person at the side of the patient's chest is responsible for making sure that the head and neck do not move during that removal remember that small children may require additional padding to maintain inline stabilization",
        "Review": "okay so that concludes the chapter 29 head and spine injuries chapter lecture and now let's see what we've learned all right so number one review question a part of the central nervous system it's divided into three things and we know that that is a the cerebrum cerebellum and that brain stem as you are assessing a 24 year old man with a large laceration to the top of the head you should recall that i think it's b blood loss from the scalp lacerations they contribute to hypovolemic shock they bleed a lot a patient who experiences an immediate loss of consciousness followed by a lucid interview now what kind of do you remember what kind of bleed that was and that was an epidural hematoma okay and that's an artery epidural artery 44 year old male who was struck in the back of the head and was reported unconscious for approximately 30 seconds he complains of a severe headache and seeing stars and states that he's regained his memory shortly after your arrival what does he present with and that is a concussion okay concussion a young male he's involved in a motor vehicle accidents experience a closed head injury he has no memories of the events leading up to the accident and that he was going to the birthday party what is the term we use for for um documenting this now leading up to the event that's retrograde retrograde amnesia the um the actual event is that anterior grade amnesia a distraction injury to the cervical spine would most likely occur following hanging type some type of hanging type mechanism during a mobilization of a patient with a possible spinal injury manual stabilization of the head must be maintained until the patient's fully immobilized on that long backboard your patient is a 21 year old male who has massive face and head trauma after being assaulted he is laying supine semi-conscious and has blood in his mouth what should we do so we know we want to suction but first we have to manually stabilize that head right okay so manually stabilize and then we're going to log roll him and then suction man is found slumped over the steering wheel unconscious and making snoring sounds after an automobile accident his head is turned to the side and his neck is flexed what should we do we need to manually stabilize and move it into the neutral inline position right okay and finally you should not remove an injured football player's helmet if if and what is it the face guard can easily be removed and there's no array compromise we're going to leave that in place okay well thank you for joining me for chapter 29 this is the head and spine injuries lecture if you like this lecture go ahead and subscribe to the channel because we're going to put together the whole book the lectures throughout the whole book okay thank you and have a good night"
    },
    {
        "Introduction to Face and Neck Emergencies": "hello and welcome to chapter 28 face and neck emergencies of the emergency care and transportation of the sick and injured 12th edition after you complete this chapter and the related coursework you will understand how to manage trauma related issues with face and neck you will also learn to recognize life threats associated with these emergencies and injuries and the correlation with the head and spinal trauma the curriculum includes detailed Anatomy physiology of the head neck and eye and discusses injuries including trauma to the mouth penetrating neck trauma lenot tracheal injuries and facial fractures the chapter also includes information on Dental injuries and blast injuries to the eye management of common eye injuries such as foreign objects puncture wounds lacerated eyelids Burns impaled objects and complications from blunt trauma are included okay so let's get started the face and neck are particularly vulnerable to injury because of their relatively unprotected position on the body soft tissue injuries and fractures are common and vary in severity some injuries are life-threatening such as p uh penetrating trauma to the neck may cause severe bleeding and an open injury may allow an air embolism to enter the circulatory system so let's talk about the anatomy and physiology of this area the head is divided into the following first it's the cranium and it's also referred to as the skull it contains the brain posterior portion of the cranium is called the ocit on each side of the cranium the lateral portions are called the temples or temporal regions the forehead is called The frontal region anterior to the ear in the temporal region you can feel the pulse of the super icial temporal artery the six major bones of the face",
        "Six Major Bones of the Face": "include first you have the nasal bone then you have two zagas two maxil and the mandible the Bony orbit protects the eye from injury composed of lower edge of the frontal bone and the zagmail and the nasal bones only the proximal third of the nose is formed by bone the exposed portion of the ear is composed entirely of cartilage covered by skin the external visible part is called the penina the tragus is a small rounded fleshy bulge immediately anterior to the ear canal the superficial temporal artery can be palpated just anterior to the tragus about 1 in posterior to the external opening of the ear is the mastoid process the mandible forms the jaw and Chin okay so let's move down from the head into the neck and the neck contains many important structures supported by",
        "Cervical Spine": "the cervical spine the first seven vertebrae in the cervical spine uh is C1 through C7 the spinal cord exits from The Forum mag and lies within the spinal canal formed by vertebrae the upper part of the esophagus and trachea lying in the midline of the neck the coted arteries are found on either side of the trachea along with the jugular veins and several nerves the LX which is the atoms apple",
        "Larynx": "is located in the center of the anterior of the neck the other portion of the LX is the cry cartilage and it's a form Ridge of cartilage below the thyroid cartilage the CID thyroid membrane lies between the thyroid cartilage and the CID cartilage the trachea is below the Linex the trachea connects the oral ferx and the Linex with the main passages to the lungs on either side of the lower Linex and the upper tra lies the thyroid gland",
        "Sternomastoid Muscles": "sternomastoid muscles originate from the mastoid process of the cranium and insert into the medial border of each collar bone and the sternum at the base of the neck this allows for movement of the head the eye and that's a globe shape",
        "The Eye": "approximately 1 inch in diameter is located within a bony socket in the skull called the orbit if it's composed of adjacent bones of the face and skull in adults the orbit protects over 80% of the eyeball between and below the orbits are the nasal bones and sinuses the figure on this slide",
        "Major Components of the Eye": "illustrates the major components of the eye the eye ball or Globe keeps its shape as it result of pressure from the fluid contained within the two Chambers it's clear jelly-like fluid fluid near the back of the eye is called the vitous humor in the front of the lens the clear fluid is called the aquous humor the conjunctiva is a membrane that covers the eye the lacal glands often are called Tear glands produce fluid to keep the eyes moist the tear drains in the inner side of the eye through two lacrimal ducts into the nasal cavity",
        "Sclera": "the Scara is white fibrous tissues that helps maintain the global shape and protects the more delicate inner structures on the front of the eye the Scara is replaced by clear transparent membrane called the cornea this allows light to enter the eye the iris is a circular muscle behind the cornea the pupil is the opening in the center of the iris it allows light to move to the back of the eye um a condition in which a person is born with two different Siz pupils is called aniso cor an escora the lens behind the",
        "Iris": "iris um the lens focuses images on the retina at the back of the globe the retina contains nerve endings which respond to light by transmitting nerve impulses through the optic nerve to the brain the retina is nourished by a layer of blood vessels between it and and the back of the globe retinal detachment is when the retina detaches from the underlying um choid and can cause blindness injuries to the face and neck",
        "Injuries to the Face and Neck": "so let's talk about these now injuries about the face and neck can often lead to partial or complete obstruction of the upper Airway several factors May contribute to the obstruction you could have blood clots in the upper Airway from heavy facial bleeding or direct injuries to the nose and mouth and Linex and the trachea are often the source of significant bleeding or respiratory compromise injuries may cause teeth or dentures to become dislodged into the throat swelling that accompanies direct or indirect injury to those soft tissues can also contribute to an airway obstruction the airway may also be affected when the patient's head is turned to the side Poss injuries to the brain and the cervical spine May interfere with normal",
        "Soft Tissue Injuries": "respirations so soft tissue injuries the face and neck are extremely vascular swelling in the area may be more severe skin and tissues in these areas have a rich blood supply and a blunt injury can cause a hematoma and then there's Dental injuries Okay so mandible injuries are common because of its prominence second only two nasal fractures in frequency most of these fractures are the result of vehicle collisions or assaults signs of mandible fractures include misalign teeth numbness to the chin or the inability to open the",
        "Maxillary Fractures": "mouth maxillary fractures are usually found after blunt force high energy impacts the sign of a maxillary fracture includes facial swelling inab instability of facial bones and misalignment of the teeth fractured and Evol teeth are common following facial trauma teeth fragments can become an airway obstruction and should be removed immediately okay so now we're going to",
        "Patient Assessment of the Face and Neck Injuries": "start talking about the patient assessment of the face and neck injuries and just like every patient assessment seen safety is highest priority then we're going to assess for any par potential violence or environmental hazards standard precautions require eye protection and face mask because of the potential for projectile blood now determine the number of patients and consider the need for additional resources so the mechanism of injury is going to be very important um you want to assess the scene looking for indicators of that mechanism of injury common mois for face and neck injuries include motor vehicle collisions Sports Falls penetrating trauma blunt trauma next let's talk about the primary",
        "Primary Assessment": "assessment and this let you want to focus on identifying and managing lifethreatening concerns threats to X ABC's must be treated immediately when there is life-threatening external Hemorrhage it should be addressed before the airway and breathing okay you want to form that general impression so look for important indicators of the seriousness of the patient condition injuries to the face and throat may be very obvious but may also be hidden by collars or hats control blood loss with direct pressure consider the need for spinal immobilization and check the responsiveness using your avpo scale Airway and breathing so ensure clear and patent Airway if the patient is unresponsive or has significantly altered level of Consciousness consider a properly sized oral faren gal quickly ass assess for adequacy of bleeding splinting or otherwise restricting the chest well motion is contraindicated you do not want to attempt this now is the C so assess the pulse and quality and significant bleeding is an immediate life threat of course and then the D the transport decision so consider quickly transporting patients with an airway or breathing problem or with a significant bleeding stabilization and maintenance of the airway and breathing as well as control of bleeding may be very difficult in patients with face and neck injuries consider Advanced life support um backup if the transport is too long patient with internal bleeding must be transported quickly for treatment by a physician signs of hypo profusion imply the need for Rapid transport the patient who has a sign significant mechanism of injury but whose condition appears stable should also be transported promptly remember that any significant blow to the face or throat should increase your suspicion of spinal or brain injury even if the patient has no signs of hyper profusion or hypoperfusion or other life-threatening injuries there is a possibility of eye",
        "History Taking": "injuries history taking so investigate the chief complaint obtain medical history be alert for injury specific signs and symptoms be aware of the pertinent negatives such as no pain or any loss of sensation next get that sample history and attempt to gather from friends or family if the patient's unresponsive if unresponsive patient you will only be able to notice signs of injuries and then is your secondary assessment so if multiple symptoms are likely to be affected start with assessment of the entire body looking for that Decap btls do not delay transport to complete a thorough physical exam in a responsive patient who has an isolated injury with limited mechanism of injury consider focusing your physical examination ensure the control of bleeding is maintained and note the location of that injury inspect the wound for any foreign matter and stabilize the objects during the physical exam use both your eyes and your hands if your patient is responsive you should explain exactly what you're going to do and what you're looking for and assess all underlying systems when evaluating the eyes start with the outer aspects and work towards the pupils visual Acuity is considered",
        "Visual Acuity": "the Vital sign of the eye when it comes to vital signs you want to assess an main those baselines so that you can observe for any changes during treatment you must be concerned with visible bleeding and unseen bleeding inside the body cavity with facial and throat fractures Baseline information about respirations and pulse are very important in used monitoring devices and your reassessment you want to repeat that primary reassess vital signs in the chief complaint and continually reassess the adequacy of Airway breathing and circulation recheck patient interventions this is particularly important in patients with facial or neck injuries because the ease in which the injuries can affect the associated symptom systems the patient's condition should be reassessed at least every 5",
        "Interventions": "minutes as for interventions you must provide complete spinal immobilization to any patient with suspected spinal injuries you want to maintain an open Airway be prepared to suction the patient and consider an oral fenal whenever you suspect significant bleeding profi provide high flow oxygen and control any significant visual bleeding if the patient has any signs of hypo profusion treat the patient aggress aggressively for shock and provide rapid transport do not delay transport of a seriously injured patient to complete non-li saving treatments in the field",
        "Documentation and Communication": "documentation and communication in your documentation include a description of the mechanism of injury and the position in which you found the patient emergency medical care so treat soft tissue injuries to the face and neck the same as soft tissue injuries Elsewhere on the body assess the X ABC's and life threats first follow standard precautions in the absence of life-threatening bleeding the first step is to open and clear the airway avoid moving the neck in the patients with suspected cervical injury control bleeding by applying direct pressure with a sterile dry dressing use roller guys unwrapped around the circumference of the head and to hold the pressure dressing in place do not apply excessive pressure If there is a possibility of underlying skull fracture and when an injury uh exposes the brain eye or other structures cover the exposed Parts with a moist stero dressing apply ice locally to injuries that do not break the skin enforce soft tissue injuries around the mouth check for bleeding inside the mouth Physicians can sometimes graft a piece of an Evol skin back into the appropriate position if you find portions of a v skin wrap them in sterile dressing place them in a plastic bag and keep them cool if the skin is still attached in a loose flap place the flap in the position that it as close to normal as possible all right so then we're going to talk about emergency care for specific injuries and first we're going",
        "Injuries to the Eyes": "to talk about injuries to the eyes okay",
        "Eye Injuries": "and so eye injuries are common particularly in sports and they can produce lifelong complications including blindness so proper emergency treatment will minimalize pain and may prevent a permanent loss of vision after an injury pupil reaction or shape of the eye movement are often Disturbed abnormal pupil reactions sometimes are a sign of a brain injury rather than an eye injury treatment starts with a thorough exam so look for specific specific abnormalities or conditions that may suggest the nature of the",
        "Foreign Objects": "injury foreign objects the orbit protects the eye from penetration of large objects even a very small object May produce severe irritation so irrigate with a sterile saline solution and it will and frequently flush away loose small particles gentle irrigation usually will not wash out foreign objects which are stuck to the cornea or underlying upper eyelid under the upper eyelid if you spot a foreign object on the surface of the eyelid you may be able to remove it with a moist cotton tipped applicator and so you could uh follow the skill drill in 28-1 okay so foreign bodies they may be impelled in the eye and those must be removed by The Physician your care involves stabilizing the object and preparing the patient for transport and you could follow the steps in skill drill 28-2 when you see or suspect an impaled object in the eye bandage both eyes with soft soft bulky dressing to prevent further damage or injury Burns of the eye so first of course we need to stop the burn and prevent for further damage when it comes",
        "Chemical Burns": "to chemical burns usually caused by acid or alkaline Solutions flush the eye with water or sterile solution to irrigation Solution Direct the amount of irrigation solution or water into the eye as gently as possible the figure on this slide demonstrates four ways to irrigate the eye you could use a nasal canula you could do the shower a bottle or a basin okay so chemical burns you may have to force the lids open flush from the inner to the outside corner if the burn was caused by a an alkaloid or a strong acid irrigate continuously for at least 20 minutes after irrigation apply clean dry dressing and cover the eye and transport when it comes to Thermal burs",
        "Thermal Burns": "during a fire the eyes will close to protect them from heat however eyelids are frequently burned and require Specialized Care cover both eyes with a sterile dressing U moistened with sterile saline then you could have light burns so infrared Rays uh Eclipse light and laser beams can cause significant damage to the sensory cells of the eye retinal",
        "Retinal Injuries": "injuries caused by exposure to extreme bright light are generally not painful but may result in permanent damage superficial Burns of the eye can result in Al from ultraviolet Rays from an arc welding light light from prolonged exposure to a sunlamp or reflected light from a bright snow covered area it may be painful at first but they may become painful within 3 or 4 hours later so severe conju titis usually develops with red swelling and excessive tear production cover each eye with a sterile moist pad and an Eye shield lacerations and these require very careful repair to restore appearance and function if there is a laceration of the globe itself apply no pressure to the eye gently apply a moist sterile dressing to prevent drying and cover the injure with a protective metal shield cup or sterile dressing to prevent drying and apply a soft dressing to both eyes on rare occasions the eyeball may be dislodged from the socket do not attempt to reposition it cover the eye and stabilize it with moist sterile dressing cover both eyes to prevent further injury because of sympathetic movement have the patient lipine to prevent loss of fluid from the eye and then there's blunt trauma to the eye okay so you could have an orbit fracture or a blowout fracture bone fragments can entrap some of the muscles that control the eye movement causing double vision protect the injured eye with a metal shield and cover the eye to minimize movement with a um on another on the other injured side okay so eye",
        "Eye Injuries Following a Head Injury": "injuries following a head injury so there's signs and symptoms of a possible head injury and these could be when one pupil is larger than the other or the eyes are not moving together or pointing in different directions failure of the eyes to follow movement of your fingers is um if it's if you instruct them to do that and they cannot do that so bleeding under the conjunctiva protrusion or bulging of an eye management what you want to do is keep the eyelids closed and cover the lids with moist gauze or hold them closed with clear tape then you could have blast injuries",
        "Blast Injuries": "and so signs and symptoms of blast injuries rain from Rage from severe pain and loss of vision to worn objects within the globe management of injuries",
        "Management of Injuries to the Eye": "to the eye depends on the severity of the injury and then there's contact lenses or artificial eyes in general do not attempt to remove them except for chemical um Burns um to remove hard contact lenses use a small cup um suction cup and these are specially made for those contact lenses okay to remove soft ones place one or two drops of Sal in the eye you could gently pinch the lens between your glove thumb and index finger okay place the lens in a container with some steril saline solution and advise the hospital if the patient is wearing contact lenses care for the an artificial eye as you would for a normal one the figure on this slide it'll show you how to remove hard contact lenses and soft contact lenses okay next we're going to talk about injuries to the nose and nose bleeds which are um epistases are a common problem okay and one of the most common causes is digital trauma it's characterized into anterior and posterior epistasis and anterior nose bleed usually originally from the area of the septum and bleed fairly slowly posterior nose bleeds are usually more severe and often cause blood to drain into the back of the patient's throat blunt trauma to the nose may be associated with fractures and soft tissue injuries of the face head injuries and injuries to the cervical spine so you want to assess the nose structures for injury this slide shows um the two Chambers which are divided by that septum patients with severe nasal injury may also have that cervical spine injury and cerebral spinal fluid so CSF May Escape down through the nose following the fracture to the base of the skull control bleeding by applying",
        "Control Bleeding": "sterile dressing if the patient is bleeding heavily it can be a result of significant trauma so for a non-trauma patient who's bleeding from the nose Pace the patient place the patient in the sitting position leaning forward and pinch the nostrils together now we're going to talk about",
        "Injuries to the Ear": "injuries to the ear okay so these are divided into three parts external middle and inner and the figure on the slide shows the structures of the inner",
        "Inner Ear": "ear ears are often injured but they do not usually bleed very much so if local pressure does not control the bleeding apply a roller dressing in case of a severe um ear evulsion wrap the evulse part in a moist sterile dressing and place it in the plastic bag labeled with the patient's name a tanic membrane",
        "A Tympanic Membrane Rupture": "rupture sudden changes in pressure create a blast wave can cause a rupture impatients will report severe pain difficulty hearing or ringing in that affected ear it may be caused by insertion of objects too far into the ear so Children Place foreign objects into that auditory canal all foreign objects or bodies should not be removed um by you they need to be removed by a physician so do not try to manipulate the foreign body because you could put push it back further into the ear clear fluid coming from the ear May indicate a skull fracture and next we're going to talk",
        "Facial Fractures": "about facial fractures and so in addition to external Hemorrhage there's a danger of blood clots lodging in that upper Airway and causing obstruction plastic surgeons can repair the damage to the face and mouth if the injuries are treated within 7 to 10 days so remove and save loose teeth or bone fragments from the mouth because it is often possible to replant them remove any loose dentures and dental bridges to protect against an aoy obstruction another source of aoy obstruction is swelling and which can be extreme within the first 24 hours after injury then there's Dental injuries it",
        "Dental Injuries": "can be traumatic to the patient the injury may be traumatic and the patient's permanent teeth may be lost bleeding will occur within a two and when it's violently displaced from the socket so apply direct pressure to stop the bleeding perform suctioning if needed and cracked or loose teeth are possible Airway obstructions so save and transport that tooth um handling it by the crown rather than the root and place the tooth in a tooth storage solution hold milk or a sterile saline then injuries to the cheek so if",
        "Injuries to the Cheek": "you're unable to control bleeding and it compromises the airway consider removing the object provide direct pressure on both sides inside and out okay of the cheek the amount of bandaging should not be so overwhelming though that it udes the mouth and makes it difficult to breathe and then with injuries to the neck the neck contains many structures and it's very vulnerable to injury by Blood trauma any crushing injury of the upper part of the neck is likely to involve the Linex or trachea fractures of the upper Airway and Lal cartilage so signs and symptoms include include loss of voice difficulty swallowing severe and sometimes fatal Airway obstruction and leakage of air into soft tissues of the neck this is called subcutaneous osma management of this so maintain the airway and immediately transport you want to consider Advanced life support early and also consider spinal motion restriction when it comes to penetrating trauma in that area you can uh it can cause profuse bleeding from lacerations of great vessels in the neck injuries to the crowded and jugular veins in the neck cause the body to bleed out if a vein has been punctured an air embolism may result the air the esophagus and the spinal cord can be damaged by a penetrating injury direct pressure over the bleeding sight will control most of the neck bleeding follow the steps and skild 28-3 and assess for signs of shock immediate spinal motion restriction if indicated and apply high flow oxygen when it comes to laryngeal",
        "Laryngeal Injuries": "injuries and this is blunt force trauma it can cause the Linex to be injured um it's usually an unrestrained driver who strikes the steering wheel or possibly maybe a snowmobile Rider or an off Bo off-road bike rider that strikes a closed line or a fixed wire the LX can become crushed against the cervical spine resulting in soft tissue injury fractures or separation of the fascia these strangulation injuries can also be found in either intentional or unintentional hangings anytime there is suspected injury to the Linex suspect possible cervical spine injury penetrating or impelled objects in leics should not be removed unless they interfere with CPR stabilize all impaled objects if they are not obstructing the",
        "Significant Injuries to the Larynx": "airway significant injuries to the LX pose an immediate risk of Airway compromise and of course signs and",
        "Symptoms of a Larynx Injury": "symptoms of aaronic injury include respiratory distress hor horseness pain difficulty swallowing cyanosis pale skin sputum in the wound um subcutaneous empyema bruising on the neck hematoma and bleeding so you want to provide oxygen and ventilate and then sepine but avoid the use of a rigid collar okay okay so that includes chapter 28 the face and neck injuries lecture next we're just going to go",
        "Review Questions": "through the review questions to see what we've learned okay so which of the following statements regarding the app Adam's apple is false which one is it inferior to the CID is it formed by the thyroid is it the uppermost part of the lonex or is it more prominent in men and women all right and so it is a it is inferior to the CID cartilage that is incorrect okay the ey is also called do you guys remember and that's the eyeball D so it's D when a person is looking at an object of close the pupil should do you guys remember so the pupil should allow the light to move to the back of the eye and it is going to constrict when caring for a chemical burn to the eye the empty should right so when we're when we're um doing flushing the eye we need to flush it away from the uninjured eye and so that's what it was it was to prevent contamination of the opposite eye okay",
        "Five Which of the Following Signs Is Least Indicative of a Head Injury or Indicative of a Head Injury": "so number five which of the following signs is least indicative of a head injury or indicative of a head injury and we know it is pupilary constriction to the bright light because that's what it's supposed to do right pupils are supposed to constrict okay and what do we think is the purpose of the station tube what is it supposed to do and it's the middle air and it is supposed to equalize pressure in the middle layer when external pressure changes when caring for a patient with facial trauma the EMT should be most concerned with well I'm going to say Airway compromise that is big big deal no Airway no patient the presence of subcutaneous empyema following trauma to the face and throat is most Su suggested of so crushing injuries of that uh Linex okay so tracheal injuries and that is because air is escaping just right underneath this right under the skin right so subcutaneous EMP AA formed number nine a 21-year-old male has a large laceration to his neck when you assess him you knowe bright red blood is spurting so we know that that is an",
        "Arterial Bleed": "arterial bleed from the left side of the neck what should you do with an arterial bleed all right so here we go you're going to place your GL hand over it first and I'm sure you're going to put some type of dressing bandage on it which of the following mechanisms of injury would most likely cause a crushing injury to the lonx or trachea all right so GSW car crash patient whose head hits the windshield and right away you could see the attempted suicide by a hanging okay okay so thank you for joining us today for chapter 28 face and neck injuries and if you like this uh lecture go ahead and subscribe to the channel because we're going to complete the whole book thank you"
    },
    {
        "Introduction": "hello and welcome to chapter 32 orthopedic injuries of the emergency care and transportation of the sick and injured 12th edition after you complete this chapter and the related coursework you will understand the anatomy and physiology of the muscular skeletal system you will have learned the proper assessment for a suspected and obvious injury you will learn general and specific types of muscle skeletal injuries including fractures sprains and dislocations with associated signs and symptoms and emergency treatment including the use of splints and traction splits so let's get started the human body is well designed system in which form upright posture and movement are provided by the muscular skeletal system the system also protects vital internal organs of the body the musculoskeletal injuries are among the most common reasons why people seek medical attention muscular skeletal injuries are often easily identified because of pain swelling and deformity although musculoskeletal system injuries are rarely fatal they often result in short or long term disability do not focus solely on the musculoskeletal injury without first determining that life that no life-threatening injuries exist",
        "Anatomy and Physiology of the Musculoskeletal System": "so let's talk about the anatomy and physiology of the muscular cell cell system so you have three types of muscles skeletal smooth and cardiac muscles skeletal muscles also called striated muscle because of the characteristic stripes attach to the bones and usually cross at at least one joint they're called voluntary muscles because it is under direct control of the voluntary system and the responding two commands that move specific body parts it makes up the largest portion of the body's muscle mass all skeletal muscles are supplied with arteries veins and nerves skeletal muscle tissue is directly attached to the bone by tendons nexus we're going to talk about smooth muscle and that's involuntary muscles and they perform much of the autonomic work of the body they're found in the walls of most tubular structures of the body and they contract and relax to control the movement of the contents within these structures and then there's cardiac muscle and it is specially adapted involuntary muscle with its own regulatory system all right so let's talk about the skeleton next the skeleton gives us our recognizable human form protects vital internal organs and allows us to move it's made up of approximately 206 bones the bones also produce red blood cells in the bone marrow and serve as a reservoir for important minerals and electrolytes the figure on this slide illustrates the human skeleton the skull is a solid volt like structure that surrounds and protects the brains then you have the thoracic cage which protects the heart lungs and great vessels then you have the lower ribs protect the liver and spleen the bony spinal canal encases and protects the spinal cord and the pectoral or shoulder girdle consists of two scapula and two clavicles the scapula which is the shoulder blade is a flat e triangular bone held to the rib cage by powerful muscles that buffer it against injuries the clavicle otherwise known as the collarbone is a slender s-shaped bone attached by ligaments to the sternum on one end and to the acronym process on the other end because the clavicle is slender and very exposed this bone is vulnerable to injury the figure on this slide shows the pectoral girdle in the anterior and posterior view the upper extremities extend from the shoulder to the fingertips and is composed of the upper arm which is the humerus elbow and forearm which is the radius and ulna it joins the shoulder girdle at the joint and then the humerus connects to the bones of the forearm to form a hinged elbow joint then you have the hand and it contains three sets of bones the wrist bones which are the carpals hand bones are the metacarpals and the single finger bones which are the phalanges okay then moving down you have the pelvis and it supports the body weight and protects the structures within the pelvis the bladder rectum and female reproductive organ pelvic girdle is three separate bones the ilium ischium and pubis and it's fused together to form the hip joint the lower extremities consist of bones of the thigh leg and foot the femur which is the thigh bone is long it's a powerful bone that it connects in a ball and socket joint to the pelvis and in a hinged joint to the knees the lower leg consists of two bones the tibia and phibia and then there's the foot the foot consists of three classes of bones you have the ankle joints which are the tarsals the foot bones which are the metatarsals and the toe bones which are the phalanges the bones of the skeletal system provide a framework to which the muscles and tendons are attached a joint is formed wherever two bones come into contact so joints are held together in a tough fibrous structure called a capsule which is supported and strengthened in certain key areas by bands of fibrous tissues called ligaments in moving joints the ends of bones are covered with a thin layer of cartilage known as articular cartilage joins are bathed and lubricated by synovial joints and joints allow circular motion such as the shoulder joint or hinge motion such as the elbow and knee or minimal motion such are such as the sterno clavicular joints or no motion such as sutures in the skull so let's talk about",
        "Mechanism of Injury": "some muscular skeletal injuries first we need to talk about the mechanism of injury so significant force is generally required to cause fractures and dislocations and the force can be direct blows indirect forces twisting forces or high energy forces a significant mechanism of injury is not always necessary to fracture a bone a slight force can easily fracture a bone that is weakened by a tumor infection or osteoporosis suspects the pro presence of a fracture in an older patient who reports pain or has sustained a mild injury so let's talk about fractures first and fracture is a break in the continuity of the bone often occurring as a result of an external for force it's classified as either open or closed with an open fracture there is an external wound and it's caused either by a same blow that fractured the bone or by a broken bone and lacerating the skin you should treat any injury that breaks the skin as a possible open fracture complications of open fractures include increasing blood loss increased blood loss and a higher likelihood of an infection fractures are also described by either or whether the bone is moved from its normal position so a non-displaced fracture also known as a hairline fracture is a simple crack of the bone that may be difficult to distinguish from a sprain or contusion a displaced fracture produces an actual deformity or distortion of the limb by shortening rotating or angulating it so simple terms to describe particular types of fractures include green stick fracture oblique fracture pathologic fracture or incomplete fracture also there's the community fracture it's a fraction which the bone is broken into more than two fragments you could have the fracture and that's um a fracture that occurs in the growth section of the child's bone that may lead to growth abnormalities in that bone and then a green stick fracture and that's an incomplete fracture that passes only part part way through the shaft of the bone and then we talked about the incomplete that's a fracture that does not run completely through the bone an oblique is a fracture in which the bone is broken at an angle across the bone and then of course the pathologic that's a fracture of a weakened or diseased bone generally produced by minimal force the spiral and that's a fracture caused by twisting force causing an oblique fracture around the bone and through the bone and then a transverse that's a fracture that occurs straight across the bone suspect a fracture if one or more of the following signs and symptoms are present if you have a deformity or tenderness guarding or swelling bruising crepitus false motion exposed fragments pain or a locked joint",
        "Dislocations and Sprains": "okay we just talked about fractures now let's talk about some of the dislocations so a dislocation is a disruption of a joint in which the bone ends are no longer in contact supporting ligaments are often torn usually completely allowing the bone ends to separate completely from each other a fracture dislocation is a combination injury at the joint in which the joint is dislocated and there's also a fracture at the end of one or more of the bones sometimes a dislocated joint will spontaneously reduce or return to its normal position before your assessment you will be able to confirm the dislocation only by taking a patient's history a dislocation that does not spontaneously reduce is a serious problem commonly dislocated joints include fingers shoulders elbows and knees signs and symptoms of a dislocated joint are similar to those of a fracture so there's going to be marked deformity swelling pain that is aggravated by any attempt to move it tenderness on palpation virtually complete loss of a normal joint motion and we call this a locked joint or numbness or impaired circulation of the limb or digit okay we just talked about dislocations and fractures now let's talk about sprains so a sprain occurs when a joint is twisted or stretched beyond its normal range of motion the supporting capsular and ligaments are stretched or torn brains can be from they could range from mild to severe and the most vulnerable joints are the knees shoulders and ankles after the injury the alignment generally returns to a fairly normal position okay so signs and symptoms of spray sprains include guarding swelling and echomosis pain or instability of the joint and then there's a strain a strain is basically a pulled muscle and it's stretching or tearing of the muscle it causes pain swelling and bruising of the soft tissues in the area unlike a sprain no ligament or joint damage typically occurs often no deformity is present and only minor swelling is noted at the site of the injury most patients will have extreme point tenderness okay and then we're gonna talk about amputation so an amputation is an injury in which an extremity is completely severed from the body this injury can damage every aspect of the muscular skeletal system from bone to ligament to muscle so now let's talk about complications of",
        "Complications of Musculoskeletal Injuries": "these muscular skeletal injuries so orthopedic injuries can lead to numerous complications not just those involving the musculoskeletal system but also systematic changes or illness okay so the likelihood of a complication is often related to the strength of the force that caused the injury the injury's location and the patient's overall health to prevent contamination following an open fracture you should brush away any obvious debris on the skin surrounding an open fracture before applying a dressing do not enter or probe an open fractured site you can help reduce the risk of long-term disability by preventing further injury reducing the risk of wound infection and transporting patients to the appropriate medical facility",
        "Assessing the Severity of Injury": "assessing the severity of an injury so the golden period is critical not only for life but also for preserving limb viability in an extremity with anything less than complete circulation prolonged hypoperfusion can cause significant damage any suspected open fracture or vascular injury is considered a critical emergency remember that most injuries are not critical",
        "Patient Assessment": "so now let's talk about the patient assessment of these muscular skeletal injuries always look at the big picture evaluating the overall complexity of the situation to determine and treat any life threats you must be able to distinguish mild injuries from severe injuries because some severe injuries may compromise neurovascular function which could threaten long-term function all right so let's get into it the scene size up scene safety of course is number one and try to identify the forces with the associated mechanism of injury standard precautions may be as simple as gloves but a mask and gown may be necessary consider the possibility that there may be hidden bleeding evaluate the need for law enforcement support advanced life support or additional ambulances okay so the mechanism of injury so we already said look for those indicators be alert for both primary and secondary injuries consider what injuries the mechanism of injuries would lead you to expect and then there's the primary assessment so focus on identifying and managing life threats and treating the patient according to his or her level of consciousness and the ex-abcs is always priority remember the x is that massive hemorrhaging or extinguination so checking for responsiveness using the avpu scale consider high flow oxygen via non-rebreather or a bvm to the patients whose level of consciousness is less than alert and oriented ask about the mechanism of injury if there is significant trauma or multi-body systems are affected the muscular skeletal injuries may be the lower priority fractures and sprains usually do not create airway and breathing problems focus on determining whether the patient has a pulse has adequate perfusion or is bleeding if the skin is pale cool or clammy the capillary refill time is slow treat your patient for shock immediately maintain a normal body temperature and stabilize injuries in extremities prior to moving the patient and then there's your transport decision so if the patient you are treating has an airway or breathing problem or significant bleeding provide rapid transport to the nearest hospital for treatment a patient who has significant mechanism of injury but whose condition appears otherwise stable should also be transported promptly when a decision for rapid transport is made you can use a backboard as a splinting device to splint the whole body rather than splinting each extremity individually patients with a simple mechanism of injury may be further assessed and their condition stabilized on scene prior to transport if there's no other problems that exist",
        "History Taking": "okay now we're going to talk about the history taking you're going to obtain a medical history and be alert for injury-specific signs and symptoms and any pertinent negatives obtain a sample history for all trauma patients and how much and in what detail you explore the history depends on the seriousness of the patient's condition and how quickly you need to transport him or her to the hospital opqst can be limited use in cases of severe injury and is usually too lengthy when you're talking about matters of the airway breathing or circulation and rapid transport require immediate attention",
        "Secondary Assessment": "and then there's your secondary assessment so it's basically that physical exam and if significant trauma has likely affected multiple systems start with a secondary assessment of the entire body to be sure you have found all of the problems and injuries begin with that head to toe work systemically towards the feet checking the head chest abdomen extremities and back the goal is to identify hidden and potentially life-threatening injuries use the dcap btls approach to assess the muscular skeletal system when lacerations are present in any extremity an open fracture must be considered bleeding control and dressings must be applied any injury or deformity of a bone may be associated with vessel or nerve injury obtain a baseline neurovascular assessment and always recheck the neurovascular function before you splint and otherwise manipulate the limb examinations of an injured limb should include the six p's of the musculoskeletal assessment pain paralysis paresthesia which is numbness or tingling pulselessness power and pressure and then determine a baseline set of vital signs",
        "Reassessment": "and then there's the reassessment of course repeat the primary assessment to ensure your interventions are working as they should a reassessment should be performed every five minutes for unstable patients and 15 for stable interventions we're going to assess the patient's overall condition stabilize the xabc's and control any serious bleeding in a critically injured patient you should secure the patient to the long backboard to minimize the spine pelvis and extremities and provide prompt transport to a trauma center in this situation a secondary assessment is a waste of valuable time reassess the patient and route to the emergency department and if the patient has no life-threatening injuries you can take the extra time at scene to stabilize the patient's overall condition after assessing the extremity apply a secure splint commercial or otherwise to stabilize injury prior to transport and then there's the communication and documentation so you need to document complete descriptions of the injuries and the mois associated with them document the presence of absence or of circulation motor function or sensation distal to the extremity in that is injured after manipulation or splinting the injury and on arrival at the hospital all right so let's talk about",
        "Emergency Medical Care": "the emergency care for these patients perform a primary assessment and stabilize the patient's ex abcs if needed perform a secondary assessment of either the entire body or the specific area of injury be alert for signs and symptoms of internal bleeding and follow the steps in skill drill 31 or 32-1 when caring for patients with musculoskeletal injuries splinting a splint is a flexible or rigid device that is used to protect and maintain the position of an injured extremity unless the patient's life is in immediate danger you should split off fractures dislocations and sprains before you should move the patient it reduces pain and makes it a lot easier to transport and transfer the patient so when you splint it will help prevent the following further damage to the muscles spinal cord peripheral nerves and blood vessels if um um from broken ends bone ends in a laceration of the skin by broken bones it could restrict restriction of blood vessel flow resulting from pressure of bone ends on blood vessels or excessive bleeding of tissues at the injury site caused by broken bones increased pain from movement of the bone ins and paralysis of the extremities general principles of splinting you want to remove the clothing from that area of any suspected fracture or dislocation so that you can inspect the extremity for that d-cap btls note and record the patient's neurovascular status distal to the site of the injury including pulse sensation and movement cover open wounds with dry stale or sterile dressings before splinting do not move the patient before splinting an extremity unless there is an immediate danger to the patient or unless there are threats defined in the primary assessment of the ex-abcs that are unable to be corrected if a suspected fracture of the shaft of the bone be sure to stabilize the joints above and below the fracture and with injuries in and around the joint be sure to stabilize the bones above and below the injured point pad all rigid splints to prevent local pressure and discomfort to the patient when applying the splint maintain manual stabilization to minimize movement of the limb and support the injury site if the fracture of the long bone shaft has resulted in severe deformity use constant gentle manual traction to line the limbs so that it can be splinted if you encounter resistance to the limb alignment splint the limb in its deformed position mobilize at all suspected spinal injuries in a neutral inline position on the backboard and if the patient has signs and symptoms of shock align the limb in the normal at atomic position and provide transport when in doubt splint",
        "Rigid Splints": "so let's talk about rigid splints rigid are non-formable splints and are made from firm material and are applied to the sides front and back of an injured extremity to prevent motion at the injury site follow the steps in skill drill 32-2 there are two situations in which you must split the limb in the position of deformity and that's when the deformity is severe and when you encounter resistance or pain when applying gentle traction to the fracture of a shaft of the bone",
        "Formable Splints": "after rigid splints we're going to talk about formible splits and these are sam splints and it stands for suction or splints and vacuum splints okay and you are most likely to use a our structural aluminum manual that's a sam splint and vacuum splints other examples include air splints pillow splints and sling and swath splints a vacuum splint can be easily shaped to fit around a deformed limb instead of pumping air in however you can use a hand pump to pull the air out through the valve follow the steps in skill drill 32-3 to apply a vacuum splint next we're going",
        "Pelvic Binder": "to talk about pelvic binders those are used to splint the bony pelvis to reduce hemorrhage from bone ends venous disruption and pain",
        "Hazards of Improper Splinting": "all right so hazards of imp improper splinting compressions can result of nerves tissues and blood vessels also there's a dislay and transport of the patient with a life-threatening injury you could reduce the distal circulation or aggravate the injury or also injure to tissues nerves blood vessels or muscles as a result of excessive movement of the bone or joint",
        "Transportation": "so transportation very few if any muscular skeletal injuries justify the use of excessive speed during transport if a patient has a pulseless limb it must be given a high priority so if the treatment facility is an hour or more away a patient with a pulseless limb should be transported by a helicopter or immediate ground transportation",
        "Injuries of the Clavicle and Scapula": "so let's talk about specific muscular skeletal injuries okay and um so the clavicle or collar bone is one of the most commonly fractured bones in the body it occurs commonly in children when they fall with an outstretched hand and a patient with a fracture to the clavicle will report in the pain in the shoulder and will usually hold the arm across the front of his or her body generally swelling and point tenderness occur over the clavicle the clavicle lies directly under or over major arteries veins and nerves therefore fracture of the clavicle may lead to neurovascular compromise fractures of the scapula or shoulder blade occur much less frequently because the bone is well protected by many large muscles always almost always result in of a forceful direct blow to the back directly over the scapula it is associated with chest injuries not the fractured scapula itself that pose the greatest threat of long-term disabilities so abrasions contusions and significant pain will occur and the patient will often limit the use of the arm because of the pain at that fractured site okay so the joint below the outer end of the clavicle and the acronym process of the scapula is called the acro clavicle joint or the ac joint this joint is frequently separated during sports such as football or hockey when a player falls and lands on the point of the shoulder driving the scapula away from the outer end of the clavicle these fractures can all be splinted efficiently efficiently with a sling and swath",
        "Dislocation of the Shoulder": "then there's the dislocations of the shoulder so basically the humeral head most commonly dislocates anteriorly coming to lie in front of the scapula as a result of forceful adduction and external rotation of the arm shoulder dislocations are extremely painful some patients may report numbness in the hand because of the either the nervous or circulatory compromise stabilizing an interior shoulder dislocation is difficult because any attempt to bring the arm in towards the chest wall will produce pain you must splint the joint in whatever position is most comfortably comfortable for the patient i slinged the forearm and wrist to support the weight of the arm wouldn't secure the arm in a sling to a pillow and chest with a slo swath transport the patient in a seated or semi-seated position",
        "Fracture of the Humerus": "all right so now let's talk about fractures to the humerus and they occur either approximately in the mid shaft or distally at which at the elbow and with any severe angulated fracture you should consider applying traction to realign the fractured fragments before splinting them port the site of the fracture with one hand and with the other hand grasp the two humeral condyles just above the elbow pull gently in line with the normal axis of the limb splint the arm with a sling and swath supplemented by a padded board splint on the lateral aspect of the arm then there's elbow injuries so fractures and dislocations often occur around the elbow and the different types of injuries are difficult to distinguish without a radiographic examination they all produce similar limb deformities and require the same emergency care fracture of the distal humerus this type of fracture is known as a supracondylar or intracondylar fracture and it's common in children frequently the fractured fragments rotate significantly producing deformity and causing injuries to nearby vessels and nerves swelling occurs rapidly and is often severe and then there's dislocation of the elbow so this type of injury occurs in athletes and rarely in young children the ulna and radius are most often displaced posteriorly relative to the humerus type of injury there is swelling and significant potential for that vessel and nerve injuries all right so then a fracture of that process of the ulna so it can result in direct or indirect forces and is often associated with lacerations and abrasions and patients will be unable to actively extend the elbow with this type of fracture and then there's fractures of the radial head and it's often missed during diagnosis it generally occurs as a result of a fall on an outstretched arm or a direct blow to the lateral aspect of the elbow attempts to rotate the elbow or wrist can cause discomfort so let's talk about care of all of these elbow injuries all elbow injuries are potentially serious and require careful management always assess diesel distal neurovascular functions periodically with patients with elbow injuries if you find strong pulses and good cap refill splint the elbow injury in the position in which you found it adding a wristling if it seems helpful if you find a cold pale hand or weak absent pulse or poor capillary refill it indicates that the blood vessels have likely been injured if the limb is pulseless and significantly deformed at the elbow apply gentle manual traction in line with the long axis of the limb to decrease the deformity and provide prompt transports for all patients with impaired distal circulation",
        "Fractures of the Forearm": "then we're going to now we're going to talk about fractures to the forearm so seen most often in children and older people usually bros both bones break at the same time when the injury is a result of a fall of an outstretched hand in isolated fractures of the shaft of the ulna it may occur as a result of a direct bloat to it such as a nice stick fracture fractures of the radius distal radius which are especially common in elderly patients with osteoporosis are known as a cole's fracture to stabilize fractures of the forearm and wrist you can use padded board air vacuum or pillow splits",
        "Injuries of the Wrist and Hand": "and then there's injuries to the wrist and hand so dislocations are usually associated with a fracture resulting in a fracture dislocation another common wrist injury is an isolated non-displaced fracture of the carpal bone especially at the scapuloid so because of the fingers and hands are required to function in such intricate ways any injury that is not treated properly may result in permanent disability as well as deformity so you want to follow the steps and skill drill 32-4 to splint the hand and wrist next we're going to talk about fractures of the pelvis so it often results from a direct compression in the form of a heavy blow that laterally crushes the pelvis it may be accompanied by life-threatening blood loss from a laceration of blood vessels effects affixed to the pelvis at certain key points up to several liters of blood may drain into that pelvic space and in the retroperitoneal space which lies between the abdominal cavity and the posterior abdominal wall and it can result in significant hypotension shock and death pelvis fractures can lacerate the rectum vagina and bladder suspect a fracture of the pelvis in any patient with this who sustained a high velocity injury and complains of discomfort in the lower back or abdomen deformity or swelling may be very difficult to see the most reliable signs of a fracture of the pelvis is simple tenderness or instability on a firm compression and palpation assess for tenderness patients in stable condition can be secured to a long backboard or scoop stretcher to stabilize isolated fractures to the pelvis the figures on this slide show how to assess a pelvic region for tender or instability",
        "Dislocation of the Hip": "and then you have dislocations of the hip so the hip is a very stable ball and socket joint it dislocates only after significant injury most dislocations of the hip are posterior most commonly occurring as a result of a motor vehicle crash in which the knee meets with the direct force and the entire femur is driven posteriorly dislocation of the hip is associated with very distinctive signs severe pain resistance of movement tenderness on palpation and the ability to palpate the femoral head deep within the muscles of the buttocks as with any injury do not attempt to reduce the dislocated hip in the field unless medical control directs you to do so splint the dislocation in the position of deformity and place the patient supine on a long backboard support the affected limb with pillows and rolled blankets to secure the limb to that backboard",
        "Fractures of the Proximal Femur": "all right next we're going to talk about fractures of the proximal femur so fractures of the proximal end of the femur are common fractures especially in older people and people with osteoporosis the break goes through the neck of the femur all right and across the proximal shaft of the femur patients display very characteristics deformity they lie with one leg externally rotated and the injured limb is usually shorter than the opposite uninjured limb patients typically are unable to walk or move that leg and the hip region is usually tender on palpation and gent gentle rolling of the leg will cause pain but will not do further damage you want to assess the pelvis for any soft tissue injury and bandage splint the lower extremity and transport to the emergency department patients with patients may have significant blood loss so you treat with high flow oxygen my monitor vital signs and be alert for signs of shock",
        "Femoral Shaft Fractures": "okay now let's talk about femoral shaft fractures so it can occur in any part of the shaft from the hip region to all the way down to the knee joint what happens following the fracture is the large muscles of the thigh spasm in any attempt to splint that unstable limb the muscle spasm often produces significant deformity of that limb so fractures may be open and there is often a significant amount of blood loss and it is not unusual for hypovolemic shock to develop because of the severe deformity that occurs with these fractures bone fragments may penetrate or press on important nerves and vessels and produce significant damage so carefully and periodically assess the distal neurovascular function in these patients cover any wound with a dry steroid dressing and a fracture of the femoral shaft is best stabilized with a traction splint such as a sagger splint",
        "Traction Splints": "let's talk about traction splints neck so these are used to secure fractures of the shaft of the femur which are characterized by pain swelling and deformity of the mid thigh excessive traction can be harmful to an uninjured limb so goals of inline traction include we want to stabilize fractured fragments to prevent excessive movement and align the limbs significantly to allow it to be placed on the splint um avoid potential neurovascular compromising do not use attraction splint for any of the following conditions so we're not going to use them in an upper extremity or injuries close or at evolving the knee or injuries of the pelvis then we're not using it for partial amputations or avulsions with bone separation or lower leg foot or any ankle injury to apply a hair traction splint we're going to follow the step steps and skill drill 32-5 and the following steps in skill drill 32-6 to apply the sagger traction splint now we're going to talk about injuries to knee ligaments the knee is very vulnerable to injury ligament injuries range from mild sprains to complete dislocations of the joint the patella can also dislocate any bone elements of the knee can fracture okay so the knee is especially vulnerable to ligament injuries which occur when abnormal bending and twisting forces are applied to the joint the patient will report pain in the joint and be unable to use the extremity normally so swelling bruising tenderness and fluid in the joints are generally present you should splint all success suspected knee ligament injuries the splint should extend from the hip joint to the foot stabilize the bone with the injured um injured joint and bone below it a variety of splints can be used included a padded rigid long leg splint or two padded board splints when it comes to dislocations of the knee these are true emergencies that may threaten the limb when the knee is dislocated the ligaments that provide support to it may be damaged or torn always check the distal circulation carefully before taking any other step the direction of the dislocation refers to the position of the tibia with respect to the femur so posterior knee dislocation are the most common they occur in most in almost half of the cases the medial dislocations result from a direct blow to the lateral part of the leg patients will typically complain of pain in the knee and report that the knee gave out complications include limb threatening patello artery disruption injuries to the nerves and joint instability if adequate distal pulses are present splint the knee in the position in which you find it and transport promptly medical control may instruct you to attempt to realign a deformed pulseless limb to reduce compression of that popliteal artery and restore that distal circulation all right so fractures about the knee so they may occur at the distal end of the femur or at the proximal end of the tibia or in the patella management of two types of injuries are as follows so if there is adequate distal pulses and no significant deformity splint the limb with the knee straight if there is an adequate pulse and significant deformity splint the knee and the position of the deformity if the pulse is absent below the level of the injury suspect possible vascular and nerve damage and contact medical control never use attraction splint if you suspect a fractured knee",
        "Dislocation of the Patella": "all right now let's talk about dislocations of the patella so usually the dislocated patella displaces to the lateral side the displacement produces a significant deformity in which the knee is held in a moderately flexed position and the patella is displaced to the lateral side of the knee splint the knee in the position in which you find it most often this is with the knee flexed to a moderate degree apply a padded board splint to the medial and lateral aspects of the joint extend from the hip to the ankle injuries to the tibia and phibia so fracture of the shaft of the tibia amphibia occur at any place between the knee joint and the ankle joint often both bones are fractured at the same time even a single fracture may result in severe deformity with significant angulation or rotation often fractures of the tibia are relatively common these fractures should be stabilized with padded rigid long leg splints or an air splint that extends from the foot to the upper thigh correct severe deformity before splinting by applying gentle longitudinal traction",
        "Ankle Injuries": "and then there's ankle injuries so the ankle is commonly in injured joint and ankle injuries occur in people of all ages and range in severity from a simple sprain to a severe fracture dislocation in ankle injuries that produce pain swelling localized tenderness or the inability to to bear weight it must be evaluated by a physician the most frequent mechanism of an ankle injury is twisting which stretches or tears the supporting ligaments you want to manage injuries to the ankle as the following so dress all open wounds assess distal neurovascular function correct any gross deformity by applying gentle longitudinal traction to the heel before reassessing traction apply the splint and then there's foot injuries so they can result in the dislocation or fracture of one or more of the tarsals metatarsals or phalanges of the toes frequently the force of the injury is transmitted up the legs to the spine producing a fracture of the lumbar spine if you suspect the foot is dislocated immediately assess for pulses and motor and sensory functions if pulse is present immobilize the extremities using a splint leaving the toes exposed to assess neurovascular function if the pulses are absent contact medical control injuries to the foot are associated with significant swelling but rarely with gross deformity to splint the foot apply a rigid padded board splint or air splint or a pillow splint stabilizing the ankle joint and the foot leave the toes exposed when the patient is laying on the stretcher elevate the foot approximately six inches to minimize swelling",
        "Strains and Sprains": "okay sprains and strains treat every severe sprain as if it's a fracture general treatment is to that of the fracture and includes rice's okay so rest ice compression elevation and splinting",
        "Amputations": "then there's amputations so you want to control bleeding and treat for shock surgeons today can occasionally reattach amputated parts with partial amputations make sure to immobilize the part with bulky dressing and splint to prevent further injury do not sever any partial amputations control any bleeding from the stump and if bleeding severe quickly apply a tourniquet with a complete amputation make sure to wrap the clean part in a sterile dressing and place it in a plastic bag follow local protocols regarding how to preserve amputated parts the goal is to keep the part cool without allowing the part to freeze or develop frostbite the amputated part should be transported with the patient to the appropriate resource hospital",
        "Compartment Syndrome": "next let's talk about a condition called compartment syndrome compartment syndrome is a limb threatening condition characterized by local tissue swelling within the compartment blood flow decreases inside the muscle compartment ischemia results in anaerobic metabolism results tissues become damaged and can die definitive treatment is a surgical procedure called aphasiotomy an incision through the skin and fascia allows the swollen muscle to expand reducing pressure inside the compartment compartment syndrome typically develops within six to 12 hours after the injury usually as a result of excessive bleeding a severely crushed extremity and the rapid return of pulse to that ischemic limb signs and symptoms include pain that is out of proportion to the injured extremity pain on a passive stretch of the muscles within the compartment and altered sensation additional signs may occur pallor and decrease power okay if you suspect that a patient has compartment syndrome splint the affected limb keeping it level of the heart and provide immediate transport reassess neurovascular status frequently during transport",
        "Review": "okay so that concludes chapter 32 and we're going to go ahead and go through the review questions to see what we've learned okay skeletal muscle is also referred to and if you remember us talking about it it is striated muscle and that is because of those lines in the muscle so striated muscle you respond to a soccer game for a 16 year old male with severe ankle pain when you deliver him to the hospital a physician tells you that he suspects a strain that means what does that mean that means c so stretching or tearing of those ligaments with partial or temporary dislocation of the bone ends a young male with a musculoskeletal injury is unresponsive you will not be able to assess what will we be able to assess and we know that that's probably the sensory sensory right can you feel this or can you move this because he's unconscious the purpose of splitting a fracture is to well we want to prevent those motions of the bony fractures and making uh reducing any further injuries right a motorcycle has crashed his bike and has a closed deformities to both of his mid shaft femurs he's conscious but restless has skin is cool and clammy and his radial pulses are weak and rapid the most appropriate splinting techniques would be i think we should probably put him on a long backboard yep um along securing him to the long backboard allowing the long backboard to act as the splint to effectively mobilize a fractured clavicle you should what should we do and we are just going to do that sling and swath and that's going to help minimize the movement of that the clavicle a patient tripped fell and landed on their elbow she's in severe pain and has obvious deformity to her elbow what do we want to do we know that the very first thing we do is we manually stabilize the injury and then we assess for that pms so manually stabilize as always first when treating an open fracture you should and we know that we want to prevent more infection so they want us to cover that wound to prevent that more infection which of the following musculoskeletal injuries is the greatest risk for shock due to blood loss let's see femurs are pretty bad but also pelvic fractures pelvic fractures have those large vessels inside and so it would be as a result of slicing with those large vessels so it's pelvic fracture a injured patient has an injured knee riding a bicycle she's laying on the ground and her leg is flexed with severe pain she can't move it you reassess obvious deformity to her left knee distal pulses are present and strong the most appropriate treatment is what is the most appropriate treatment and that's going to be a dislocation so we want to make sure that we splint the leg in the position that it's found okay so that concludes uh chapter 32 lecture and review questions if you like this lecture go ahead and subscribe to the channel because we're going to complete the book"
    },
    {
        "Introduction to Bleeding": "hello class and welcome to chapter 26 bleeding of the emergency care and transportation of the sick and injured 12th edition",
        "National EMS Education Standard Competencies": "after you complete this chapter and the related coursework you will understand the structure and function of the circulatory system the significance and characteristics of bleeding the importance of personal protective equipment when treating a bleeding patient the characteristics of external versus internal bleeding how to conduct a patient assessment and the methodologies for controlling bleeding okay so let's get started recognizing",
        "Importance of Understanding Bleeding": "bleeding and understanding how it affects the body is an important skill bleeding can be external and obvious or internal and hidden so either type of bleeding is potentially dangerous and can cause weakness shock and death uncontrolled bleeding is the most common cause of hypoperfusion following a traumatic injury",
        "Anatomy and Physiology of the Cardiovascular System": "so the anatomy and physiology of the circulatory system our cardiovascular system so the cardiovascular system circulates blood to all the body's cells and tissues it delivers oxygen and nutrients carries away metabolic waste products and it's responsible for supplying and maintaining adequate blood flow the contents are the pump which is the heart the container which are the blood vessels and the fluid which is the blood and the body fluids so let's talk in depth about those three things so the heart it needs a rich and well distributed blood supply it works as two paired pumps you have the upper chamber which is the atrium and the lower chamber which are the ventricles and blood leaves each chamber through a one-way valve this figure shows the right and left sides of the heart next you have the blood vessels and blood so there are types of blood vessels and those are called arteries arterioles and capillaries and also venules and veins oxygen and nutrients easily pass from capillaries into the cells and waste and carbon dioxide diffuse from the cells back into the keplers blood contains red blood cells and that's responsible for the oxygen transportation and the carbon dioxide you have white blood cells and those are responsible for fighting infection platelets those are the form the blood clots and then the liquid part which is the plasma so blood clot formation depends on several factors the blood stasis changes in the blood vessel walls such as a wound or the blood's ability to clot and that's affected by disease or medication",
        "Autonomic Nervous System": "so let's talk about the autonomic nervous system this monitors the body's needs and adjusts blood flow by constricting or dilating blood vessels it automatically redirects blood away from other organs to the heart brain lungs and kidneys in an emergency and it adapts to changing conditions in the body and maintains homeostasis and perfusive if the system fails to provide significant circulation for every body part to perform its function shock results",
        "Pathophysiology and Perfusion": "so let's talk about the pathophysiology and perfusion so perfusion is the circulation of blood within an organ or tissue in adequate amounts to meet the cell's current needs for oxygen nutrients and waste removal the speed of blood flow must be fast enough to maintain adequate circulation throughout the body and to avoid clotting and it must be slow enough though to allow cells time to exchange oxygen and nutrients for carbon dioxide and other waste products some tissues need a constant supply blood while others can survive with very little blood all tissues and organs organ systems of the human body depend on adequate perfusion to function properly and some organs cannot tolerate interruption of a blood supply for more than a few minutes without sustaining damage death of an organ system can quickly lead to death of a patient the heart requires a constant flow of blood so let's talk about external bleeding and this is this hemorrhage means bleeding and external bleeding is a visible hemorrhage the significance of external bleeding with serious external bleeding it may be difficult to tell the amount of blood loss blood will look very different on different surfaces so it's important to estimate the amount of external blood loss the body will not tolerate an acute blood loss of greater than 20 percent blood volume so that's about two pints adverse changes and vital signs may occur with significant blood loss so you'll see an increase in heart rate an increase in respiratory rate and a decrease in blood pressure how well people compensate for blood loss is related to how rapidly they bleed so an adult can comfortably donate one unit or about 500 milliliters of blood over a period of about 10 to 20 minutes if a similar blood loss occurs in a much shorter period of time the person may rapidly develop signs of hypovolemic shock the age and pre-existing health of the patient should be also considered so let's talk about some characteristics of external bleeding you should consider bleeding to be serious if the following conditions are present so if you see a poor general appearance and no response to external stimuli signs and symptoms of shock significant blood loss rapid blood loss uncontrolled bleeding or significant mechanism of injury okay so let's talk about the different types of bleeding so you have you could have arterial or venous and so with arterial pressure causes blood to spurt and makes bleeding difficult to control it's typically brighter red and spurts in time with the pulse okay then you have venus and that's dark red it does not spurt it's easy to manage and more likely to clot spontaneously than arterial bleeding it can be profuse and life-threatening however and then you have capillary bleeding so this is dark red and oozes from a wound steady but slowly more likely to clot spontaneously than arterial bleeding",
        "Clotting Process": "so let's talk about the clotting process okay so bleeding tends to stop rather quickly within about 10 minutes in response to internal mechanisms and exposure to air so when the skin is broken blood flows rapidly from the open vessel the cut ends of the vessel begin to narrow and this is called vasoconstriction it reduces the amount of bleeding then a clot forms bleeding will never stop if the clot does not form unless the injured vessel is completely cut off from the main blood supply by direct pressure or a tourniquet",
        "Hemophilia": "with hemophilia the patient lacks one or more of the blood clotting factors and so bleeding may occur spontaneously and all injuries no matter how trivial are potentially serious so patients should be transported immediately if they're hemophiliac",
        "Internal Bleeding": "let's talk about internal bleeding and this can be very serious because it is not easy to detect immediately injury or damage to internal organs commonly result in extensive internal bleeding it can cause hypovolemic shock possible conditions causing internal bleeding include you could have a stomach ulcer or a lacerated liver a ruptured spleen perhaps broken bones",
        "MOI for Internal Bleeding": "often the signs of internal bleeding are contusions or echomosis a mechanism for injury for internal bleeding so a high speed mechanism of injury should increase your index of suspicion for the possibility of a serious unseen injury blood trauma and penetrating trauma so we use the pneumonic d-cap btls to assess for signs of injuries and this is deformities contusions abrasions punctures penetrations burns lat tenderness laceration swelling and any other signs of injury",
        "NOI for Internal Bleeding": "okay nature of illness for internal bleeding and so internal bleeding is not always caused by trauma possible non-traumatic causes can be ulcers or bleeding in the colon maybe a ruptured atopic pregnancy or perhaps aneurysms it is not important for you to know the specific organ involved as it is to recognize a patient who is in shock and respond appropriately so signs and symptoms of internal",
        "Signs and Symptoms of Internal Bleeding": "bleeding occur include pain and that's the most common okay so you can have swelling in the area of the bleeding distension leading into the chest cavity or lung you could have a hematoma or bruising so bleeding from any body opening so if it's bright red bleeding from the mouth or rectum you could have hematuria or non-menstrual vaginal bleeding in hemiamesis and that's vomiting blood so if it's bright red or dark red coffee ground appearance malena and that's black foul smelling tarry stool and it's digested blood basically or pain tenderness bruising gardening or swelling and that could be possible close fractures or broken ribs which and you'll might see bruising over the lower part of the chest or a rigid distant abdomen okay so hypoperfusion is hypovolemic shock and change in mental status such as anxiety restlessness or combativeness you could have weakness faintness or dizziness on standing change in the skin later signs of hypoperfusion suggesting internal bleeding include tachycardia weakness fainting or dizziness thirst nausea and vomiting cool moist clammy skin or shallow rapid breathing could have dull eyes slightly dilated pupils that are slow to respond to light kept refill of more than two seconds in infants and children weak rapid pulse decreasing blood pressures altered mental status or patients with these signs and symptoms require prompt transport so let's do the patient assessment okay so we're going to do the scene size up and we're going to be alert for potential hazards in a violent incident make sure the police are on scene and we want to follow standard precautions so we're going to consider the mechanism of injury and the need for spinal immobilization and additional resources okay next is our primary assessment",
        "Primary Assessment": "we do not want to be distracted from life threats so we need to form our general impression and we need to know important indicators that alert us for the seriousness of the patient's condition we are going to perform a rapid exam so if the patient has obvious life threatening external bleeding address it first and assess skin color determine the level of consciousness using the avpoo scale okay next we're going to do the abcs and our d but first the airway and breathing so we have to ensure that patent airway of course high flow too and we're going to assist with ventilations via bag valve mass device or a non-rebreather and we're going to insert an oral pharyngeal to secure the airway if the patient is unconscious then circulation we're going to assess the pulse rate and quality determine skin condition color and temperature cap refill time and we're going to control external bleeding and treat for shock next is the d so we're going to do that transport decision we're going to assess the abcs and life threats to determine rapid transport patients who may have significant pleading will quickly become unstable okay so signs that imply the need for rapid transporting clues include tachycardia tachypnea low blood pressure weak pulse or clammy skin so next let's do the history taking and of course we're going to investigate that chief complaint we're going to look for signs and symptoms of other injuries due to the mechanism of injury or the nature of illness then we're going to do the sample history so we want to ask the patient if they're taking blood thinning medications so if the patient is unresponsive obtain history information from medical alert tags or bystanders and look for signs and symptoms of shock determine how much blood loss estimated",
        "Secondary Assessment": "and then of course our secondary assessment we're going to assess all areas using looking for d-cap etls the head we're looking for uncontrolled bleeding from a large scalp laceration the abdomen we want to feel all four quadrants for tenderness or rigidity the extremities we're going to record pulse motor and sensory functions and we're going to record vital signs with a critically injured patient or a short transport time there may not be time to conduct a secondary assessment then we're going to do that reassessment so the patient frequently especially in the areas that show abnormal findings during the primary assessment and we're going to reassess any unstable every five and stable every 15 minutes some of the interventions we're going to provide are high flow o2 we're going to control external bleeding we're going to provide treatment for shock and transport rapidly and if internal bleeding is suspected we're going to put on high flow 2 via non-rebreather mask and provide rapid transport we do not want to delay transport of any patient to complete any assessments and of course we have to communicate and document so we have to recognize estimate and report the amount of blood loss and how rapidly or over what period of time it occurred we want to communicate all relevant information to the staff at the receiving hospital including all injuries the care provided and the patient's response",
        "Emergency Medical Care for External Bleeding": "so emergency care for external bleeding now we need to follow standard precautions and what we need to do is wear a mask gloves eye protection and sometimes a gown we want to make sure that the patient has an open airway and is breathing adequately we want to provide high flow oxygen and if obvious life-threatening bleeding is present we have to control it as quickly as possible there are several methods to control this external bleeding first we're going to use direct pressure then pressure dressings or splits we could use tourniquets or hemostatic dressing or wound packing",
        "Direct Pressure": "so let's talk about direct pressure the most common ineffective way to control external bleeding the pressure stops the flow of blood and permits normal coagulation to occur we want to apply pressure with our glove fingertip or hand over the top of sterile dressing for an object protruding from the wound apply bulky dressing to stabilize that object in place and apply pressure the best you can hold uninterrupted pressure for at least five minutes",
        "Pressure Dressing": "then there's the pressure dressing so firmly wrap a sterile self-adhering roller bandage around the entire room wound stretch the bandage tight enough to control the bleeding you should still be able to palpate a distal pulse on the in injured extremity after applying the dressing do not remove the dressing until the physician has evaluated the patient apply additional manual pressure through the dressing if necessary just add more dressings over the first if it bleeds through and the tourniquet is a useful is useful if the patient has substantial bleeding from the injury and it cannot be controlled with direct pressure so you could apply the tourniquet above the level of bleeding if this is not possible consider additional tourniquet or wound packing with the hemostatic dressing if available so we want to follow the skill drill 26-1 to demonstrate the basic techniques to control external bleeding",
        "Hemostatic Agents": "next we're going to talk about wound packing and hemostatic dressing so this is gauze and it can be packed into larger wounds to control hemorrhaging when direct pressure is not adequate or application of a tourniquet is not possible so a hemostatic dressing is impregnated with a chemical compound that slows or stops bleeding by promoting clot formation it can be used together with wound packing and direct pressure when direct pressure alone is ineffective or when a tourniquet placement is otherwise impossible so we're going to follow the skill drill on 26 desk 2 to demonstrate the basic techniques for wound packing",
        "Tourniquets": "okay and tourniquets of course if direct pressure does not control that extremity bleeding then use a tourniquet a tourniquet is only useful if the patient has substantial bleeding from that extremity injury and we're going to follow the skill drill uh skill drill in our book on 22 26-3 to demonstrate applying a commercial tourniquet and then there's junctional tourniquets and allow for a proximal compression of life-threatening bleeding in areas where a standard tourniquet application is not possible such as the groin or axilla area it may be indicated for severe hemorrhage at the junction of the torso with the arms and the legs so some junctional tourniquets may be used as such as a pelvic binder",
        "Splints": "okay and then you have air splints so you can control internal and external bleeding associated with severe extremity injuries you could immobilize fractures or it could also act like a pressure dressing applied to an extreme an entire extremity with um rather than to a small local area okay and then you have the pelvic binder this is a type of splint that may be indicated for a suspected closed unstable pelvic fracture it helps to control internal bleeding specifically bleeding associated with a life-threatening open-book pelvic fracture",
        "Bleeding From the Nose, Ears, and Mouth": "then there's bleeding from the nose ears or mouth so several conditions can result in bleeding from the nose ears mouth and they include the following so you could have a skull fracture or facial injury have some type of sinusitis or an infection or use and abusive nose drops dried or cracked nasal mucosa or some other abnormality um perhaps high blood pressure coagulation disorder disorders or digital trauma or cancer so epistasis that's a nosebleed okay it's common emergency occasionally can cause enough blood loss to lead the shock the blood you see may only be a small part of the blood loss because much the blood may pass down the patient's throat into the stomach as the patient swallows a person who swallows a large amount of blood may become nauseated and start vomiting and um so most nontraumatic nosebleed occur from sites in the septum and that's the tissue dividing the nostrils so you can usually handle this type of bleeding effectively by pinching the nostrils together and there's a skill drill showing you how to do that on 20-26-4 in your book okay so bleeding from the nose or ears following a head injury so this may indicate a skull fracture and it may be difficult to control do not attempt to stop that blood flow to supply uh applying excessive pressure to the injury may force the the blood leaking through the ear or nose to collect in the head so loosely cover the bleeding site with a sterile gauze pad to collect the blood and keep contaminants away from the site apply light compression by wrapping the bulky dressing around the head a target or halo shaped stain may occur on a dressing if the blood or drainage contains cerebral spinal fluid and you can see the photo of that halo on the slide",
        "Emergency Medical Care for Internal Bleeding": "so emergency care for internal bleeding controlling internal bleeding or bleeding from a major organ usually requires surgery or other hospital procedures so try to keep the patient calm reassure and still and as quiet as possible you can give them high flow too maintain body temperature splint the injured extremity usually with an air splint never use a tourniquet to control bleeding from a closed internal or soft tissue injury and follow the skill drill on 26-5 to care for patients with internal bleeding okay so that concludes chapter 26 bleeding chapter and let's see what we've learned so which of the following is not a component of the cardiovascular system okay and right away we know lungs lungs that's the respiratory system perfusion is most accurately defined as i think it's c circulation of enough oxygen and nutrients as significant amounts a man involved in a motorcycle crash has multiple abrasions and lacerations which of the following injuries is the highest treatment priority hmm widespread abrasion three inch laceration dark flowing blood laceration the form with obvious debris or one inch lacerations thigh squirting okay so we know that's that arterial so d perfect which of the following sets of vital signs least indicative of internal bleeding least well i would think it would be a yes a um and uh okay when caring for a patient with internal bleeding the emt must first okay we know we want to control the bleeding so that's an obvious life threat but we also have to ensure there's an airway but very first we have to take the appropriate standard precautions so all of the interventions must be her form however we have to take standard precautions first the quickest and most effective way to control external bleeding from an extremity is direct pressure that's right direct pressure when applying a tourniquet to an amputated arm the emt should let's see the emt should apply the tourniquet over the joint avoid applying it yes okay we have a 70 year old man who's experiencing a nosebleed when we arrive we find him leaning over basin which contains an impressive amount of blood he has a history of coronary artery disease diabetes migraine headaches oh his blood pressure's high his heart rate's a little elevated which of the following is the most likely the contributing factor i'm going to say it's going to be the high blood pressure yes okay when caring for a patient with um epistasis the most effective way to prevent aspiration of blood is too  i think it's going to be b yep lean forward tilt them forward okay and controlling internal bleeding requires surgery usually right yes internal bleeding controlling is a surgical intervention okay so that concludes chapter 26 the bleeding chapter um if you like this lecture go ahead and subscribe to the channel all right have a great night"
    },
    {
        "Introduction": "hello and welcome to chapter 25 the trauma overview chapter of the emergency care and transportation of the sick and injured 12th edition",
        "National EMS Education Standard Competencies": "after you complete this chapter and the related coursework you will have an understanding of the basic concepts of energy and its effects on the human body the general injury patterns associated with different types of impacts falls and penetrating trauma and the basic application of laws of physics on the assessment of trauma patients you will begin to demonstrate critical thinking and making predictions of injuries and adjusting index of suspicion based on the analysis and of evidence gathered in the scene size up you will also understand some common injury patterns to major body systems",
        "Introduction to Trauma": "okay so let's get started for people younger than 44 years old traumatic injuries are the leading cause of death in the united states trauma emergencies occur as a result of physical forces applied to the body whereas medical emergencies occur from an illness or condition not caused by an outside force so evaluation of the mechanism of injury for a trauma patient will provide you with an index of sufficient for different types of serious or life-threatening underlying injuries index of suspicion is your awareness and concern for potentially serious underlying and unseen emergencies",
        "Energy and Trauma": "so let's talk about energy and trauma so traumatic inner injury occurs when the body's tissues are exposed to energy levels beyond their tolerance mechanism of injury describes the forces or energy transmission acting on the body that causes the injury there are three concepts of energy and they're typically associated with injury you have potential energy kinetic energy and energy of work energy can be neither created nor destroyed it can only be converted or transformed so work is defined as force acting over distance forces that bend or compress tissue bodies beyond their inherent limits result in the work that causes the injury okay so kinetic energy is the energy of a moving object it reflects the relationship between the mass which is the weight of the object and the velocity which is the speed at which it's traveling okay potential energy is a product of the mass force of gravity and the weight mostly associated with the energy of falling objects",
        "Mechanism of Injury Profiles": "okay so mechanism of injury profiles so there are different types of mechanism of injury it will produce many types of injuries okay so you have non-significant mechanisms of injury and that's when the injury is to an isolated body part a fall without a loss of consciousness then you have significant mechanism of injuries okay and these can be injury to more than one body system which we call multi multi multi-system trauma fall from heights motor vehicle or motorcycle crashes car versus pedestrian or bicycle or motorcycle a gunshot wound or a stabbing",
        "Blunt and Penetrating Trauma": "okay so let's talk about blunt and penetrating trauma so traumatic injuries can be divided into two separate categories blunt trauma and penetrating trauma so blunt trauma is the result of force to the body that causes injury without penetrating the soft tissues or internal organs and cavities penetrating trauma causes injuries by objects that primarily pierce or penetrate the surface of the body and cause damage to soft tissues internal organs and body cavities so either type may occur from a variety of mechanisms of injuries",
        "Blunt Trauma": "then you have blunt trauma so blunt trauma results from an object making contact with the body so motor vehicle crashes and falls are the most common mois be alert for skin discoloration and pain as they may only be the sign of blood trauma and maintain a high index of suspicion for hidden injuries",
        "Vehicular Crashes": "okay when you have a motor vehicle crash so crash typically consists of three collisions okay so let's say there's a car against a tree then you have the tree or objects okay so by assessing the vehicle that has crashed you can often determine the mechanism of injury so the passenger against the interior car that is um one of the crashes okay and that kinetic energy produced by the passenger's mass and velocity is converted into the work of stopping his or her body and its common passenger injuries include lower extremity fractures ribs and head trauma",
        "Internal Injuries in Vehicular Crashes": "then you have the passengers internal organs against the solid structures of the body okay so internal injuries may not be as obvious as external injuries but they are often the most life-threatening so significant mechanisms of injury are associated by or suggested by death of an occupant in the vehicle okay severe deformity of the vehicle or intrusion into the vehicle moderate intrusion from the lateral from a lateral accident or severe damage from the rear or crashes in which a rotation is involved okay or an ejection from the vehicle so let's talk about the different types",
        "Frontal Crashes": "of crashes next and we're going to talk about frontal crashes first okay so evaluate the supple um the restraint system determine whether the pasture was restrained by a full or properly applied three-point restraint and determine whether the airbag was deployed seat belts and airbags are effective in preventing a second collision inside the motor vehicle so seat belts may decrease the severity of the third collision airbags decrease the severity of deceleration injuries and decrease injuries to the chest face and head despite airbags suspect injuries to extremities which uh result from the second collision or internal organs that's result from the third children shorter than four foot nine should ride in the rear seat remember that if the airbag did not inflate during the accident it may deploy during the extrication and remember that supplemental restraint systems can also cause harm if they're applied if they're applied improperly so his hip dislocations may result of seat belts award too low internal injuries can occur if the belt is worn too high and lumbar spine fractures are also possible particularly in children and older adults so look for points of contact between the patient and the vehicle as you perform a simple quick evaluation from the interior of the vehicle",
        "Rear-End Crashes": "okay so now let's talk about rear end crashes and these are known to cause whiplash type injuries particularly in the absence of a properly placed headrest as the body is propelled forward the head and neck are left behind acceleration type injury to the brain as possible and passengers in the back seat wearing only the lap belt may have a higher incident of injury to the thoracic and lumbar spine",
        "Lateral Crashes": "okay next let's talk about the lateral type crash and this is a common cause of death associated with motor vehicle accidents so a vehicle struck from the side is usually struck above the center of gravity it begins to rock away from the side of the impact as a result in the passenger sustaining a whip-like whiplash type in injury if there is substantial intrusion into the passenger compartment please suggest lateral chest and abdominal injuries on the side of the impact possible fractures in the lower extremities and pelvis or ribs for organ damage from the third collision",
        "Rollover Crashes": "and then rollover crashes so large trucks and sport utility vehicles are prone to rollover because they have a high center of gravity so injuries depend on whether the passenger was restrained the most common life-threatening event in a rollover is the ejection or partial injection of the pasture from the vehicle even when restrained pastures can sustain severe injuries",
        "Rotational Crashes": "and then let's talk about rotational crashes so rotational crashes such as spins are conceptually similar to rollovers the rotation of the vehicle acid spins produces opportunities for the vehicle to strike objects such as utility poles",
        "Car Versus Pedestrian": "all right so now let's talk about the car versus the pedestrian injuries are often graphic and apparent there can also be serious unseen injuries like we talked about you should be um aware of the speed of the vehicle whether the vehicle was thrown or whether the patient was thrown through the air and at what distance and off and surface the patient landed on whether the patient was struck and pulled under the vehicle so evaluate the vehicle that was struck the patient for structural damage advanced life support should be summoned for any patient who have or are thought to have been sustained a significant mechanism of injury",
        "Car Versus Bicycle": "all right so now let's talk about car versus bicycle so we're going to evaluate the mechanism of injury in such the manner that the car versus the pedestrian crashes we want to evaluate the damage position of the position of the bicycle if the patient was wearing a helmet inspect it for damage presume that the patient has sustained an injury to the spinal cord and until proven otherwise at the hospital okay so spinal immobilization must be initiated and maintained during the encounter okay now we're at the car versus the",
        "Car Versus Motorcycle": "motorcycle and you can get protection from the helmet and uh it does not protect against severe cervical injury however and then the leather or abrasion resistant clothing and they will protect against road abrasion but not against blood trauma from secondary impacts and also there's boots that will protect the feet so when assessing the scene of a motorcycle crash look for deformity to the motorcycle side of the most damage distance of the skid in the road deformity of secondary objects or other vehicles and the extent and location of deformity in the helmet there are four types of motorcycle impacts okay so first you have the head-on and that's when the motorcycle strikes another object and stops its forward motion while the driver continues forward okay and then you have the angular crash and that's when the motorcycle strikes an object or another vehicle at an angle so that the rider sustains direct crash injuries to the lower extremity between the object and the motorcycle then there's the ejection so the rider will travel at a high speed until something stops him okay so either it's a secondary object another vehicle or a road drag then you have a controlled crash okay this is a technique used to separate the rider from the body of the motorcycle and the object to be hit is referred to as laying the bike down",
        "Falls": "okay so now that we've gotten through the cars let's move on to the falls okay the injury potential of a fall is related to the height from which the patient fell the greater the height of the fall the greater the potential energy a fall from more than 20 feet is considered significant and internal injuries pose the greatest threat to life patients who fall and land on their feet may have less severe internal injuries because their legs may have absorbed much of the energy of the fall however they may have serious injuries to the lower extremities and pelvis and spinal injuries take into account the height of the fall the type of the surface struck in the part of the body that hit first followed by the path of energy displacement",
        "Penetrating Trauma": "okay next let's talk about penetrating trauma okay so penetrating trauma is the second leading cause of death in the united states after blunt trauma there's low energy penetrating trauma and that's caused by it could be accidentally by an impalement or intentionally by something such as a knife or ice pick or another weapon with low energy penetrations injuries are caused by the sharp edges of the object moving through the body and therefore close to the object's path so knives may have been deliberately moved around internally causing more damage than the external wind suggests in a medium and high velocity penetrating trauma the path of the projectile which is usually a bullet may not be easy to predict the bullet may flatten out tumble or even ricochet within the body before exiting the path of the projectile causes its trajectory and fragmentation will increase damage so cavitation results from a rapid change in the tissue and fluid pressure that occur with the passage of a projectile temporary cavitation injuries result from the stretching of the tissue that occurs with the pressure changes and permanent cavitation injuries results closer to the bullet path and remains after the projectile has passed through the tissue the relationship between the distance and the severity of the injury depends varies on the type of weapon involved okay so air resistance often refers to the drag slows the projectile decreasing the depth of the penetration and energy of the projectile and thus reducing damage to the tissues the area that is damaged by a medium and high velocity projectiles is typically many times larger than the dynamic diameter of the projectile itself this is one reason that exome exit wounds are often many times larger than the entrance wounds the energy available for the bullet to cause the damage is more a function of its speed than its mass an important factor for the seriousness of a gunshot wound is the type of tissue through which the projectile passes so this table on the slide shows the signs of a developing problems in trauma patients",
        "Blast Injuries": "next let's talk about blast injuries so although most commonly associated with military conflict blast injuries are also seen in civilian practice and mines shipyards chemical plants and in associated with terrorist activities figure on this slide shows the four mechanisms of blast injuries so let's talk about those okay you have the um primary blast injuries and these are due to extreme entirely to the blast itself so the damage to the body is caused by the pressure wave generated by the explosion then you have the secondary blast injuries and that's the damage to the body from being struck by flying debris then you have tertiary blast injuries and the victim is hurled by the force of the explosion against a stationary object then you have the fourth type of blast injury and that's when the burns from hot gases are fired started by the blast it could be respiratory injury by inhaling the toxic gas or a crush injury from the collapse of the buildings perhaps suffocation poisoning or other medical emergencies or contamination of wounds from environmental chemical or toxic substances most patients who survive an explosion will have some combination of all four types of the injuries we just mentioned tissues at risk so organs that contain air such as the middle ear lung or the gi tract are most susceptible to pressure changes the ear is the most sensitive to blast injuries pulmonary blasts are defined as pulmonary trauma and that results from short-range exposure to a detonation of explosives a pneumothorax is a common injury and may require emergency decompression in the field one of the most concerning pulmonary blast is arterial air emboli so this happens when the um alveolar disruption of air embolism into the pulmonary vasculature okay and it can produce disturbances in vision or changes in behavior perhaps changes in the state of consciousness or a variety of neurological signs solid organs are relatively projected from shock wave injury but may be injured by a secondary missile or being hurled so neurologic injuries and head trauma are the most common causes of death from blast injuries extremity injuries including traumatic amputations are also common",
        "Multisystem Trauma": "then you have when we talk about trauma you could have multi-system trauma so what this is is when trauma involves more than one body system so you have you could have a head and spine trauma chest and abdomen chest and multiple extremity or you so you must be alert um and call medical control and transport rapidly multi-system trauma patients have a high level of morbidity and mortality",
        "Golden Principles of Prehospital Trauma Care": "so the golden principles of pre-hospital trauma care your main priority is to ensure of course your safety that's number one then we're going to do the safety of our crew then the safety of the patient we want to determine the need for additional personal and equipment of course and evaluate the mechanisms of injury we need to identify and manage life threats then focus on patient care so hemorrhage control is the highest priority of course we want to access and manage the airway including the ventilatory support and high flow oxygen while maintaining appropriate spinal restriction and that's the second priority okay then ensure that other shock therapy is completed and protect the spine and proceed with the spinal immobilization if indicated transport the patient immediately to the appropriate facility in most patients with multi-system trauma definitive care requires surgical intervention so scene time should be limited to 10 minutes or less during transport obtain the sample history and complete the secondary assessment and you also want to consider advanced life support intercept and or maybe air medical transport",
        "Patient Assessment": "okay so let's start the patient assessment portion of the lecture so when you are caring for a patient who has experienced a significant mechanism of injury and the patient is considered to be serious or critical condition you should rapidly perform the physical exam with the patient who is experiencing a significant moi focus on the chief complaint while assist assessing the patient as a whole",
        "Injuries to the Head": "so let's do injuries to the head let's talk about that disability and unseen injury to the brain may occur bleeding or swelling inside the skull is often life-threatening include frequent neurologic examinations in your assessment some patients they will not have obvious signs or symptoms until minutes or even hours after the injury has occurred",
        "Injuries to the Neck and Throat": "next we're going to talk about injuries to the neck and throat so airway problems may result that could quickly become a serious life threat your assessment must include frequent physical exams including decap hls in the neck region also assess the jugular vein distension and tracheal deviation so swelling may prevent blood flow to the brain and cause injury to the nervous system and a training injury may result in an air embolism a crushing injury to the upper part of the neck may cause the cartilage of the upper airway and larynx to fracture",
        "Injuries to the Chest": "next we're just moving down the body so injuries to the chest the chest contains the heart lungs and large vessels many life-threatening injuries may occur you could have broken ribs which may hinder bleeding bruising that may occur to the heart and cause an irregular heartbeat or large vessels of the heart may be torn inside the chest causing massive unseen bleeding also air may collect between the lung tissue and the chest wall and this is known as a pneumothorax or the collection of blood in the chest is also called a hemothorax a penetrating or perforation of the integrity of the chest is called an open chest wound okay so if this is left in treating shock may occur and it is imperative that you assess the chest region every five minutes assessment should include decap btls lung sounds and chest rise and fall",
        "Injuries to the Abdomen": "now moving down into the abdomen so the abdomen contains vital organs that require very high amount of blood flow to perform the functions necessary for life solid organs may tear lacerate or fracture which can cause serious bleeding into the abdomen solid organs include the liver spleen pancreas and kidneys then when you have hollow organs they may rupture and leak their toxic digestive chemicals into the stomach area and its causes uh could cause a life-threatening infection hollow organs include the stomach large and small intestines and urinary bladder the rupture of blood vessel can also cause a serious unseen bleeding",
        "Management: Transport and Destination": "so management so our same time survival is critical when it comes to trauma patients and so on scene time for critically injured patients should be less than 10 minutes the following criteria will help you identify a critically injured patient so was there a dangerous mechanism of injury is there decreased level of consciousness are there any threats to the airway breathing or circulation patients who are very young or very old or have chronic illness should also be considered to have a high risk all right so decision so where are we going to take them trauma centers are classified by levels one through four with level one having the most resources level one facility provides every aspect of trauma care level two facility provides initial definitive care level three it provides assessment resuscitation emergency care then stabilization and then a level four that just provides advanced trauma life support all right so the association of air medical and and med evac foundation internationally identified the following criteria for appropriate use of emergency air medical services for trauma patients so here it is there is an extended period of time to access or extricate a re remote or trapped patient the distance to a trauma center is more than 20 to 25 miles the patient needs advanced care and there is no als level ground ambulance service available traffic conditions or hospital availability make it unlikely that the patient will get to trauma center by ground there are multiple traumatic patients who will overwhelm the hospitals nearby ems systems require bringing a patient to the nearest hospital rather than bypassing a facility to go directly to a trauma center this may add delay to receiving definitive surgical care or if there's a mass casualty event trauma centers are categorized as either adult trauma centers or pediatric trauma centers but not necessarily both so types of transports so modes of transports ultimately come in one of two categories and that's ground or air so ground ems units are staffed by emts and paramedics whereas air ems units or critical care transport units are staffed by critical care nurses and paramedics okay and so this is going to show you basically a flow of the transport decision process all right so when it comes to transport and destinations so there are special considerations remain calm complete and organized assessment correct life-threatening injuries do no harm and never hesitate to contact advanced life support backup or medical control for guidance",
        "Review": "okay so that concludes the lecture portion of chapter 25 the trauma overview chapter now we're just going to see what we've learned all right so when it comes to kinetic energy it's the calculation of and i think it's the weight and speed yeah so calculation is the weight and speed which is the mass and velocity so energy cannot be destroyed only converted okay a 20 year old man has a major open facial injuries after his vehicle struck a tree head-on oof which of the following findings within the car would most likely explain the injury pattern okay so a non-intact windshield looks like it might be the head that went through um i would think so the mechanism of injury the vehicle yep that's right the non-intact windshield okay which of the following would most likely result from the third collision in the tree three collision effect that occurs during a high speed frontal impact motor vehicle crash okay frontal i'm thinking it's the aortic rush rupture or compression injury and yep so the third collision the body's internal organs keep going forward right a young male experienced severe blood chest trauma when his passenger car struck another vehicle head-on during your inspection of the interior of his vehicle which would you most likely find okay so we have blunt chest trauma chest area would be the steering wheel deformity i would assume yep and then respraying driver collided with a bridge pillar upon inspection of the interior of the vehicle you note the lower dashboard is crushed during your initial assessment of the patient you would most likely encounter i'm thinking the pelvis yep trauma to the pelvis whiplash injuries are most common following blank impacts oh i think that this is rear-end rear-end impacts yes death from a rollover motor ethical crash is most often secondary to i think that that when you get ejected from the vehicle and then the the car yep that is the ejection okay severe abrasion injuries can occur when motorcycle riders are slowed after a collision by road drag road track is most often associated with which type of motorcycle impact all right so this is going to be severe abrasion injuries occur when they are ejection from the bike okay when assessing a stab wound it's important for an emt to remember hmm i think it's d more internal damage can be present than the external one suggests yep okay and finally a 40 year old male is standing near a building when it exploded he has multiple injuries including a depressed skull fracture severe brooms burns and an impelled object in his abdomen his head injury was most likely the cause of i think it is the third the third injury right yes so it is the tertiary okay thank you for joining me for the traumatic the trauma overview chapter chapter 25 um we hope you enjoyed the lecture and um go ahead and subscribe because we'll be coming out and doing the whole book all the lectures in the whole book okay have a great night"
    },
    {
        "Introduction to Soft-Tissue Injuries": "hello and welcome to chapter 27 soft tissues injury of the emergency care and transportation of the sick and injured 12th edition after you complete this chapter and the related coursework you will have an understanding of the types of open and closed soft tissue injuries how to care for soft tissue injuries including the use of dressings and bandages and the assessment and care of different types of burns including thermal chemical and electrical burns okay so let's get started soft tissue",
        "Overview of Soft-Tissue Injuries": "injuries are common and they can be as serious as a life-threatening internal injury do not become distracted by them because they are dramatic open wounds the soft tissues of the body can be injured through a variety of mechanisms including blunt injury penetrating injury barotrauma or burns so let's break this down okay so soft tissue trauma is a common form of injuries wound care is one of the most frequently performed procedures in the emergency departments across the united states most of these injuries require basic interventions death is often related to the hemorrhage or the infection related okay so infection can be life or limb threatening especially in children and older adults and people with diabetes or other conditions that may compromise the immune system soft tissue injuries and their complications can often be prevented by using simple protective actions so let's talk about the anatomy and physiology of the skin the skin is the body's first line of defense against external forces and infection it's the largest organ in the body and it is relatively tough but still susceptible to injury injuries may expose blood vessels nerves and bones",
        "The Anatomy and Physiology of the Skin": "in some instances the emt must control bleeding prevent further contamination to decrease the risk of infection protect wounds from further damage and apply dressings and bandages to various parts of the body so skin varies in thickness depending on the person's age and the skin's location so skin is going to be thinner and very young and very old and skin is thinner in the eyelids lips and ears than the scalp back and soles of the feet the skin has two principal layers there is the epidermis and the dermis the epidermis is the tough external layer that forms a watertight covering for the body the epidermis is composed of several layers and then there's the dermis that's the inner layer of skin it contains hair follicles sweat glands and subcutaneous glands blood vessels in the dermis provide the skin with nutrients and oxygen here's a great illustration on the shot on the slide that shows the structure of the skin okay so skin covers all the external surfaces of the body the various openings in the body are lined with mucous membranes and mucous membranes provide a protective barrier against bacterial invasion okay so skin serves many functions first it's a barrier like we said against infection it's a sensory organ and it assists with regulation of body temperature it also helps maintain fluid balance any break in the skin may allow bacteria to enter and increase the possibility of infection fluid loss and loss of temperature control three types of soft tissue injuries include we there's closed open and then burns",
        "Pathophysiology of Closed and Open Injuries": "so let's talk about some of the pathophysiology of these closed and open injuries healing of wounds is a natural process that involves several overlapping stages and all directed towards the larger goal of maintaining homeostasis so the cessation of bleeding is the primary concern the next wound healing stages inflammation and that when that happens additional cells will move in to the damaged area to begin repair white blood cells migrate to the area to combat pathogens that have invaded the exposed tissue okay lymphocytes destroy bacteria and other pathogens and then mast cells release histamine inflammation ultimately leads to removal of foreign material damaged cellular parts and invading micro organisms to replace the area damaged in a soft tissue injury a new layer of cells must be moved into this region new blood vessels form as the body attempts to bring oxygen and nutrients to the injured tissue and in the last stage of wound healing collagen provides stability to the damaged tissue and joins wounds borders thereby closing the open tissue okay so closed injuries contusions they are a result from blunt force trauma striking the body the epidermis remains intact but cells within the dermis are damaged a small blood vessel or small blood vessels are usually torn the build up of blood produces a characteristic blue or black discoloration called echomosis so that's a contusion next we have a hematoma and a hematoma is a collection of blood within damaged tissues or in the body cavity okay so it occurs when a large blood vessel is damaged and bleeds rapidly um usually associated with extensive tissue damage then you have crush injuries so the extent of the damage depends on how much force is applied and how long the force was applied okay so um continued compression of soft tissue will cut off circulation producing further tissue destruction when the area of the body is trapped for longer than four hours the arterial blood flow is compromised crush syndrome can develop so when the patient's tissues are crushed beyond repair muscle cells die and release harmful substances into the surrounding tissues the harmful substance are then released into the body circulation after the limb is freed and blood flow is returned advanced life support procedures should administer iv fluid before the crush object is lifted from the body freeing the body part from entrapment also creates the potential for cardiac arrest and renal failure so consider requesting advanced life support assistance for situations of prolonged entrapment prior to extrication so compartment syndrome and this develops when edema and swelling result in increased pressure within a closed soft tissue compartment okay so pressure increases within the compartment which interferes with circulation delivery of nutrients and oxygen is prepared it's impaired and byproducts of normal metabolism accumulate there is pain especially in on passive movement the longer the situation persists the greater the chance for tissue death continually reassess skin color temperature and pulses distal to the injury site if a crush injury is suspected okay and then there's severe closed injuries and they can damage internal organs",
        "Open Injuries": "okay and then there's open injuries okay those were closed and so four types of open soft tissue wounds are abrasions lacerations avulsions and penetrating wounds an abrasion is a wound of the superficial layer of the skin caused by friction when a body part rubs or scrapes across a rough or hard surface a laceration is a jagged cut caused by a sharp object or blood force that tears the tissue and then an avulsion this separates layers of various layers of tissue so that they become either completely detached or hang as a flap often there is a significant amount of bleeding if possible replace the flap avulsion in its original position never remove it regardless of its size an amputation is an injury in which part of the body is completely severed okay and then you have penetrating wounds and they usually leave relatively small entrance wounds and produce a little inter external bleeding and then you could have an impaled object okay so an inbuilt object may damage structures deep inside the body the presence of foreign materials inside the body tissue can also lead to infection then there's stabbings and shootings and they often result in multiple penetrating injuries you can assess the patient carefully to identify all wounds and count the number of penetrating injuries especially with gunshot wounds inch in a shooting determine the type of gun when possible but do not let this delay patient transport last injuries often result in multiple penetrating injuries so the mechanism of injury from a blast injury is generally due to three factors you have three different types of blast injuries you have the primary blast injury and this is a damaged it's caused from the blast wave itself and the sudden pressure changes of the explosion then you have the secondary blast injury and this is uh as a result from damage resulting from flying debris and then you have the tertiary blast injury and that's the when the victim is thrown by the explosion and uh perhaps into another object",
        "Patient Assessment of Closed and Open Injuries": "so let's start going through the patient assessment of these open and closed injuries it is more difficult to assess a closed injury than to assess an open injury so scene size up your mechanism of injury so you need to look for indicators of that mechanism of injury as you assess the scene and this will help develop an early index of suspicion for those underlying injuries the mechanism of injury may provide information about potential safety threats as well so use all available information to evaluate scene safety and consider whether additional resources may be necessary",
        "Primary Assessment": "now is your primary assessment so focus on identifying and managing life threats and and identifying transport priority you're going to form your general impression important indicators will alert you to the seriousness of the patient's condition so is the patient awake and interacting with his her surroundings or is the patient responding to you appropriately is the patient breathing rapid or slow or what color or condition is the patient's skin and does the patient have any apparent life threats closed soft tissue injuries may appear to be minor but could indicate serious internal injuries and of course we're going to check for the responsiveness so we want to administer high flow oxygen via a non-rebreather mass to patients whose level of consciousness is less than alert treat for potential shock and provide immediate transport and next is the circulation so significant bleeding is immediate life threat and must be controlled before an airway is open okay so if the patient is has obvious life-threatening external bleeding control the bleeding first before airway and breathing this will help you also treat for shock",
        "Primary Assessment - Airway and Breathing": "so we had circulation first and now we're going to do the airway breathing so if the patient is not if the airway's not patent take the necessary steps to make sure that it is clear and patent auscultate for clear and symmetrical breath sounds and assess the for equal chest rise provide high flow oxygen and or assist ventilations if needed um if the open wound is found evaluate for air movement through the wound in the form of bubbling or sucking chest sounds so if you have some type of open chest wound and then of course your d so consider whether transport to the closest hospital is appropriate or whether the patient would be better served by a transport center okay so types of patients who need immediate transport are poor initial general impression altered level of consciousness dypsenia abnormal vital signs shock and severe pain then we're going to get to the history taking so we want to of course investigate that chief complaint because this is a trauma use sample and op qrst and then look for all the dcap btls when you're doing your assessments if the patient's not responsive attempt to obtain the history from another source chronic medical conditions such as anemia and hemophilia as well as a host of other medical conditions will complicate open soft tissue injuries",
        "Secondary Assessment": "you need to assess interventions and repeat vital signs which typically occur and route to the emergency department assess all autonomic regions looking for any of the following signs and symptoms look for the neck for jugular vein distension and tracheal deviation check the pelvis for stability check the abdomen for tenderness rigidity and bruising check the extremities and record pulse motor and sensory function the following signs indicate poor perfusion and imply the need for rapid transport and treatment at the hospital so if you have tachycardia tachypnea low blood pressure a weak pulse or cool moist or pale skin okay and then you're going to do your",
        "Reassessment": "reassessment and this should be conducted regularly during transport repeat the primary and pay extra attention to areas of concerns identified in that initial assessment and assess the effectiveness of prior treatments reassess vital signs and your chief complaint",
        "Reassessment - Continued": "and then identify and treat changes in the patient's condition okay maybe you need to reassess the bandaging or to recheck the patient's interventions",
        "Reassessment - Communication and Documentation": "and then of course we're going to communicate and document so must include a description of the mechanism and injury in the position that was found to the hospital okay we want to try and report the estimated blood loss and um so that it's easily understood by other personnel include the location and description of any soft tissue emergencies or any other wounds you have located and treated try and describe the size and the depth of the injury and provide an accurate account of how you treated these injuries",
        "Emergency Medical Care for Closed Injuries": "so let's talk about the emergency care we're going to provide okay so small contusions generally require no special emergency care but you should take note of their presence to determine the extent of the patient's injuries more extensive close injuries may involve significant swelling and bleeding beneath the skin which could lead to hypovolemic shock the injuries might not have had time to cause swelling or bruising closely watch any injury throughout the time you're caring for the patient no matter how minor it may look upon your initial assessment so treat a closed soft tissue injury using the rice's mnemonic and that is going to be rest ice compression elevation and splinting and be alert for signs and developing shock and so the it's going to be coupled with anxiety or agitation changes in mental status increased heart rate increased respiratory rate perhaps diaphoresis cooler clampy skin or decreased blood pressure and if the patient exhibits signs and symptoms of shock treat accordingly and aggressively aggressively",
        "Emergency Medical Care for Open Injuries": "before you begin to care for the patient with an open wound follow standard precautions of course and if life-threatening bleeding is observed assign a team member to apply direct pressure over the wound to control the bleeding if the wound is in the chest upper abdomen or back cover with an occlusive dressing okay and then control bleeding using",
        "Emergency Medical Care for Open Injuries - Continued": "first we're going to do direct pressure even pressure and elevation or pressure dressings or splints and possible tourniquets all open wounds are assumed to be contaminated and present a risk of infection applying a sterile dressing reduces that risk of further contamination do not remove the material from the open wound no matter how dirty the wound is okay small wound surfaces without significant bleeding can be flushed with sterile water prior to applying dresses dressings and chemical burns and contamination should be flushed to remove remaining chemicals in most circumstances hospital personnel rather than emts will clear clean open wounds in some cases you can better control bleeding from a soft tissue wound by splinting the extremity even if there's no fracture so abdominal wounds an open abdominal wound um abdominal cavity may exposed internal organs okay so in an invisceration the organs protrude from the wound cover the wound with sterile moistened gauze and have it moistened with sterile saline solution secure the guys with an occlusive dressing keep the organs moist and warm most patients with abdominal wounds require immediate transport to a trauma center and then there's impaled objects so treat this injury following the steps in skill drill 27-1 remove any impelled objects only if the object is in the cheek or mouth and it's obstructing the airway or the object is in the chest and directly interferes with cpr if the object is very long secure and then shorten it and provide rapid transport when it comes to neck injuries open neck injuries can be life-threatening it's the veins of the neck are open to the environment they may suck air in if enough air is sucked into a blood vessel it can block the blood flow in the lungs and cause cardiac arrest from an air embolism cover the womb with an occlusive dressing and manually apply pressure but do not compress both sides of the carotid arteries at the same time this could impair circulation to the brain and cause a stroke you use caution with patients suffering from neck injuries depending on the mechanism of injury involved okay and then there's bites so small animal bites and rabies so let's consider the scene and crew safety prior to entering that type of environment a small animal's mouth is heavily contaminated with bacteria so consider all small animal bites to be contaminated and potentially infected okay all small animal bites should be evaluated by a physician a major concern is the spread of rabies an acute potentially fatal viral infection of the central nervous system that can affect all warm-blooded animals children particularly small ones may be seriously injured or even killed by dogs the animal may turn and attack you as well so do not enter the scene until the animal is secured by police officer or an animal control officer and then there's human bites the human mouth more so than even a small animal's mouth contains an exceptionally wide range of bacteria and viruses consider an animal bite that has been that has penetrated the skin as a very serious injury any lacerations caused by human tooth can result in a serious serious spreading of infections so let's talk about the emergency care for these types okay so apply a dry sterile dressing appropriately immobilize the area with a splint or bandage and provide transport to the emergency department for surgical cleansing of the wound in antibiotic therapy now let's talk about burns so burns are among the most serious and painful of all injuries a burn occurs when the body or body part receives more radiant heat than it can observe and this results in an injury there are different types of sources of this injury and they include heat toxic chemical chemicals or electricity although a burn may be the patient's most obvious injury you should always perform a complete assessment to determine whether other serious injuries are present children older patients and patients with chronic illness are more likely to experience shock from burn injuries",
        "Pathophysiology of Burns": "so let's talk about the pathophysiology of burns first okay so burns are soft tissue injuries that are spread out over a large area and are created by the transfer of radiation thermal or electrical activity energy thermal burns can occur when the skin is exposed to temperatures higher than 111 degrees fahrenheit the severity of the thermal burn correlates directly with the temperature that's been exposed the concentration the amount of the heat energy which is possessed by the object or substance and the duration of the exposure burn injuries are progressive the greater the heat energy the deeper the wound exposure time is another important factor so thermal injury can occur to patients who are unresponsive or paralyzed from heat sources such as heating pads or heat lamps",
        "Complications of Burns": "now let's talk about the complications when dealing with burns so the skin serves as that barrier between the environment and the body when a person's burned the barrier is destroyed so burns create a high risk for infection hypothermia hypovolemia and shock burns to the airway are significant importance because loose mucosa in the hypopharynx swells and leads to complete airway obstructions circumferential burns of the chest can be can compromise breathing and circumferential burns of the extremity can lead to compartment syndrome which results in a neurovascular compromise and irreversible damage if not properly treated so if you suspect any complications call for advanced life support",
        "Burn Severity": "burn severity so there are five factors to determine the severity of a burn what is the depth and what is the extent are any critical areas involved such as the face upper airway hands feet or genitalia and does the patient have any pre-existing medical conditions or injuries and is the patient under five or older than 55 burns to the face are particularly important important owning to the potential of an airway involvement and burns to the hands and feet or over joints are considered serious because the potential for loss of friction as the result of scarring so the depth of the burn you could have three different types three different kinds there's first",
        "Burn Severity - Continued": "second and third remember first is superficial and it's the least it involves only the top layer of the skin which is the epidermis the burn site is often very painful example of a first degree burn is a sunburn then you have partial thickness and this is a second degree burn it involves the epidermis and some portion of the dermis these burns do not destroy the entire thickness of the skin nor is the subcutaneous tissue injured typically the skin is moist and mottled and white or red blisters are present and can cause intense pain then you have full thickness or third degree burns and they extend through all layers of the skin and may involve the subcutaneous layers muscle bone or internal organs the burned area is dry and leathery and may appear white dark brown or even charred if the nerve ending has been destroyed the severity of the bone or burn area may have no feeling the surrounding less severely burned areas may though be extremely painful and significant airway borns are serious as we mentioned earlier may be associated with some hair within the nostrils or stood around the nose or mouth or hoarseness or maybe even hypoxia so these patients should be rapidly transported to the emergency department because they're going to be needing an advanced airway management",
        "Burn Severity - Rule of Nines": "the illustration on this slide shows the damage the superficial partial thickness and full thickness burns inflict on the skin so let's talk about the extent of burns now this is going to be very important and how we calculate this is called the rule of palm there's two different types okay so the rule of palm and this can estimate the surface area that has been burned by comparing it to the size of the patient's palm which is roughly equal to one percent of the patient's total body surface then we have the rule of nines and this estimates the extent of the burn by dividing the body part into sections each progressively or each representing approximately nine percent of the total body surface area the proportions differ in infants children and adults and when you calculate the extent of the burned area include only partial and full thickness burns and document superficial burns but do not include them in the body surface area estimation of the extent of the burn injury the illustration on this slide shows how to apply the rule of nines to infant child and an adult",
        "Patient Assessment of Burns": "so let's talk about the assessment of these burns okay when you're assessing a burn it's important to classify the patient's burns so classify the burns based on the source of the burn depth and the severity",
        "Scene Size-up for Burns": "scene safety of course we want to ensure that the safe scene is safe and um the factors that have led up to the patient's burn injury do not pose a hazard for us or the crew okay so mechanism of injury we want to attempt to determine the type of burn that the patient has been sustained okay and what the patient reports will often provide important information to that extent of the injury assess the scene for any environmental hazards and determine the number of patients call for additional resources and consider the potential for spinal immobilize or spinal injuries broken bones or inhalation injuries okay comes to the primary assessment begin",
        "Primary Assessment for Burns": "with a rapid assessment you want to form that general impression look for clues to determine the severity be suspicious of clues that may indicate abuse and consider the need for manual stabilization check the responsiveness using apu and in all patients who have level of consciousness is less than alert and oriented administer high flow o2 via a non-rebreather mask and provide immediate transport your a and your b so we're going to look for singed facial hair and soot present in or around the airway heavy amounts of secretions and frequent coughing may indicate a respiratory burn then the c so circulation and control major bleeding if the patient has obvious life-threatening external hemorrhaging control the bleeding first before a and b and then treat the patient for shock treat shock in bird patients by preventing heat loss cover them with a blanket and then of course our d so we need to consider rapid transport for anybody who's having an airway issue significant burns or external bleeding and signs and symptoms of external bleeding and then we might want to consider rendezvousing with advanced life support and route so next we're going to do",
        "History Taking for Burns": "history taking so always investigate that chief complaint be alert for signs and symptoms of other injuries and if the patient was burned in a confined space definitely suspect inhalation injuries okay so we're going to obtain a medical history and be alert for injury-specific signs and symptoms and pertinent negatives and then we're going to do the sample history ask them if they're having difficulty breathing or swallowing or are they having any pain anywhere and check whether the patient has an emergency medical identification device",
        "Secondary Assessment for Burns": "your secondary assessment is going to be a physical exam of the whole entire body we're going to assess the patient from head to toe using beak dcap btls make a rough estimate using the rule of nines of the extent of the burned area determine the classification of the burns that the victim has sustained and determine the severity of the burns we're going to package the patient for transport based on our findings",
        "Secondary Assessment - Continued": "then we're going to attain the vital signs of course and we're going to use monitoring devices such as oxygen saturation and carbon monoxide we're going to reassess the patient and re-evaluate interventions and treatments and routes and then our communication and documentation we're going to provide the hospital personnel with a description of how the burn occurred the description of the extent of the burns the amount of body surface area involved the depth and location if special areas are involved they should be specifically mentioned and documented",
        "Emergency Medical Care for Burns": "okay so here we go emergency care for burns your first responsibility in caring for a patient with burns is to stop the burning process and prevent additional injury so when caring for a burn patient we're going to follow the skill the steps and skill drill 27-2",
        "Thermal Burns": "when it comes to thermal burns thermal burns are caused by heat most commonly they are caused by scolds or an open flame a flame burn is often deep and especially if the person's clothing cuts catches on fire and the skull burn is most commonly seen in children and handicapped adults but can happen anyone particularly while cooking so coming in contact with hot objects produces a contact burn and contact burns are rarely deep unless the patient was preventing from drawing away from the hot object",
        "Thermal Burns - Continued": "a steam bird can produce a topical or scald burn minor steam burns are common when",
        "Thermal Burns - Management": "microwaving food covered with plastic wrap and a flash burn is produced by an explosion which may briefly explode expose the person to very intense heat lightning strikes can cause a flash burn so let's talk about management of them of course stop the burning source we want to cool the burned area and remove all jewelry maintain a high index of suspicion for inhalation injuries increase exposure time will increase damage to the patient the larger the burn the more likely the patient is susceptible to hypothermia or hypovolemia all patients with large surface burns should have a dry sterile dressing applied",
        "Inhalation Burns": "when it comes to inhalation burns and they can they can occur when burning takes place in enclosed spaces without ventilation upper airway damage is often associated with inhalation of superheated gases and lower airway damages often associated with inhalation of chemicals or a particulate matter when treating patients with inhalation injuries you may encounter severe upper airway swelling which requires immediate intervention consider requesting advanced life support back up if the patient has any signs or symptoms of edema and so you're going to hear strider or see singed nasal hairs or perhaps burns to the face um apply cool mist air slice spray or humidified oxygen and that can help reduce some minor edema okay carbon monoxide intoxication should be considered whenever a group of people in the same place all report a headache or nausea patients with severe co2 poisoning usually will have a normal oxygen saturation hydrogen cyanide is generated by conduction signs and symptoms involve central nervous system respiratory and cardiovascular symptoms such as fainting anxiety headaches seizures paralysis or a coma okay pre-hospital treatment for patients with suspected hydrogen cyanide includes decon and supportive care and you want to just have for any toxic gas exposure recognize identify and supportive treatment is what you should",
        "Chemical Burns": "do okay chemical burns now chemical burns can occur whenever a toxic substance contacts a body most chemical burns are caused by strong acids or strong alkalis the eyes are particularly vulnerable the severity of that burn is directly related to the type of chemical concentration and duration of the exposure okay to prevent exposure to hazardous materials determine if you can safely approach the patient in some cases you must wait until the hazmat team can decon the patient okay so wear appropriate chemical resistant gloves and eye protection when you're caring for a patient with a chemical burn the treatment for chemical burns can be specific to the chemical agent and so the severity of the burn of course is going to depend on the chemical its strength and duration stop that process by removing the chemical from the patient first so if it's dry brush it off and brush it off the skin and clothing before flushing it with water and then of course remove all clothing including shoes socks gloves and any jewelry or eyeglasses take great care to ensure",
        "Chemical Burns - Continued": "that you don't come in contact with that chemical the patient should be properly deconned by properly trained personnel okay so for liquid chemicals immediately begin to flush the burned area with large amounts of water continue flooding the area with gallons of water for about 15 to 20 minutes after the patient says the burning pain has stopped if the patient's eyes are burned hold the eye open you don't want to apply pressure though but you want to flood the eye with gentle stream of water and as any substance with any substance once the fluid has been deconned with a chemical collect it and properly dispose of it",
        "Electrical Burns": "all right now electrical burns so this may be a result of contact with high or low voltage electricity so high voltage burns may occur when utility workers make direct contact with power lines or an ordinary household current can cause severe burns and cardiac dysrhythmias so for electricity to flow there must be a complete circuit between the electrical source and the ground so let's talk about the insulator and that's any substance that prevents the circuit from being completed and then there's the conductor and that's any substance that allows a current to flow through it the human body well that's a good conductor electrical burns occur when the body or part of it completes a circuit connecting a power source to the ground the type of electrical current magnitude of the current and voltage have effects on the syrian seriousness of the burns your safety is of your particular importance when you're called to the scene of an emergency involving electricity a burn injury appears where the electricity enters and exits the body two dangers specifically associated with electrical burns include um the large amount of the deep tissue injury and the patients may go into cardiac or respiratory rest from that electrical shock so the illustration on this slide shows the damage from an electrical burn management of so electrical current can cross the chest and cause a cardiac arrest or dysrhythmias if indicated we need to begin cpr okay and get an aed be prepared to defibrillate give supplemental oxygen and monitor the patient closely treat the soft tissue injuries by applying dry sterile dressings to the burn wounds and splinting suspected fractures and then of course prompt transport",
        "Taser Injuries": "oh taser injuries all right so in recent years law enforcement has increased the use of tasers so tasers fire two small darts that puncture the patient's skin barbs are generally treated as impaled objects and removed by a physician in some jurisdictions though depending on the local protocol empties are permitted to remove these barbs from the patient they are potential complications for patient when these devices have been used particularly when the patient is experiencing certain underlying disorders when it comes to excited delirium is commonly associated with illegal drug ingestion so excited delirium is a true emergency and warrants advanced life support okay using a taser device and patients with excited delirium has been previously associated with dysrhythmias and sudden cardiac arrest make sure you have access to an aed when you respond to patients who have been exposed to taser shots",
        "Radiation Burns": "and then there's radiation burns so there's a potential threat include incidents related to the use and transportation of radioactive isotopes and initially release radioactivity in terrorist attacks okay so first determine if there has been radiation exposure and then attempt to determine whether ongoing exposure continues to exist there are three types of of radiation there's alpha and they have little penetrating injury and easily can be easily stopped by the skin then you have the beta these particles have greater penetrating power and can travel much further than air than alpha they can penetrate the skin but can be blocked by simple protective clothing designed for the purposes and then there's gamma the threat from gamma radiation is directly proportional to its wavelength and it's very penetrating and easily passes through the body and solid materials",
        "Radiation Burns - Continued": "most iodizing radiation accidents involve gamma rays or x-rays people who have sustained a radiation exposure generally do not pose a risk to others but in instance involving explosions patients may be contaminated and so how to manage the types of burns you want to maintain a safe distance and wait for hazmat teams to decon most contaminants can be removed by simply removing the patient's clothes and once there is no threat to you begin treating those abcs notify the emergency deportment and identify radioactive source and the length the patient was exposed to it also identify um or limit your duration to the exposure and increase your distance from the source and attempt to place shielding between you and yours and the sources of the gamma radiation",
        "Dressing and Bandaging": "dressing in wounds okay so dressings and bandages have three functions they control bleeding they prevent the wound from further damage and they prevent further contamination and infection so you could have sterile",
        "Sterile Dressings": "dressings and most wounds will be covered by conventional four by four inch or a 4 by 8 inch or associated small adhesive type dressings and soft adherent roller dressings and then there's the universal dressing and it's ideal for covering large open wounds gauze pads are appropriate for smaller ones and adhesive type dressings are useful for minor wounds occlusive dressings prevent air and liquids from entering or exiting the wound they're made from vaseline gauze aluminum foil or plastic and used to cover sucking chest wounds abdominal eviscerations or penetrating back wounds and neck injuries",
        "Bandages": "so to keep dressings in place during transport you can use roller gauze um or rolls of gauze or triangular bandage or tape or self-adherence adhering soft roller bandages are easiest to use adhesive tape holds small dressings in place and keeps or helps to secure larger dressings some people are allergic though to that adhesive tape and with these individuals use paper or plastic tape do not use elastic bandages to secure dressings because if the injury swells the bandage may become a tourniquet and cause further damage always check a limb distal to the bandage for signs of impaired circulation and loss of sensation air splints and vacuum splints are useful if stabilizing broken extremities and can be used with dressings to help control bleeding from soft tissues and injuries if a wound continues to bleed despite the use of direct pressure quickly proceed to the use of a tourniquet",
        "Review and Conclusion": "okay so that concludes chapter 27 soft tissue injuries let's see what we learned a young man was struck in the forearm by a baseball and complains of pain in the area slight swelling and echomosis are present but no external bleeding which type of injury did we describe what do we think and it's a contusion it's a contusion from a blunt force trauma a compression injury that is severe enough to cut off blood flow below the injury is called and we know this is called compartment syndrome d 45 year old convenience store clerk was shot in the right anterior chest during a robbery your assessment reveals that wound is blood is a bubbling from every time he takes a breath the most immediate action should be what do we want to do we want to put occlusive dressing but we want to prevent air from entering the wound right that's right that's a sucking chest wound what effects will the application of ice have on a hematoma it's vasoconstriction it's going to decrease bleeding that's right vasoconstriction to decrease the bleeding the primary reason for applying a sterile dressing to an open injury is to do what we want to do reduce the risk of infection right oh no we want to we will do that but we first first first primary we want to control external bleeding that's right most appropriate way to dress and manage an open abdominal wound with a loop about protruding is we know we want to do moist sterile dressing and we want to secure with an occlusive so it's c no pressure a 22 year old male attacked by a rival gang and has a large knife in the center of his chest he's happening and pulseless uh we want to do cpr but he's got the knife there what should we do all right so we can't perform cpr if there's a knife there so we would need to carefully remove it control the bleeding and begin cpr which of the following is considered a severe burn i think it's any full thick nope severe burns are full thickness burns inverting hands feet or genitalia or more than 10 body surface so 5 or more a five-year-old burn boy was burned with when he pulled a barbecue grill over on himself he has partial and full thickness burns to the interior chest circumferentially both arms what percentage what percentage is this all right so we're doing the pediatric rule of nines the anterior truss is nine and each arm is nine so they're saying 27 percent okay and finally which of the following statements regarding chemical burns is false okay um think it's going to be c prior to removing the dry chemical because you want to remove it first yep you want to try and wipe it off first and then flush so c was wrong okay thank you for joining us for chapter 27 soft tissue injuries if you like this chapter go ahead and subscribe to our channel have a great night"
    },
    {
        "Introduction": "and welcome to chapter 31 abdominal and genital urinary injuries of the emergency care and transportation of the sick and injured 12th edition",
        "National EMS Education Standard Competencies": "after you complete this chapter and the related coursework you will understand how to manage a patient with abdominal and genital urinary trauma you will learn how to recognize life threats associated with these injuries and the need for immediate intervention the curriculum includes detailed anatomy and physiology as well as pathophysiology complications assessment and management of abdominal and genital urinary injuries the assessment section is very comprehensive and follows the primary and secondary model specific injuries discussed include blunt versus penetrating mechanisms eviscerations impelled objects injuries to external genitalia vaginal bleeding secondary to trauma and sexual assault emergency care skills include management of blunt abdominal injury penetrating abdominal injury and abdominal evisceration okay so let's get started the abdomen extends from the diaphragm to the pelvis and contains the organs that make up digestion urinary and geniturinary systems specific trauma to the abdomen can occur from blood trauma penetrating trauma or both injuries to the abdomen that go unrecognized and are not repaired in surgery are the leading cause of traumatic death",
        "Anatomy and Physiology of the Abdomen": "let's talk about the abdomen the anatomy and physiology of that so you have abdominal quadrants and the abdomen is divided into four quadrants the quadrant location of bruising or pain can tell you which organs are possibly involved in the traumatic injury and so let's take a look at these four quadrants the right lower quadrant is common location for swelling and inflammation and that's because of the appendix as a source of infection if it ruptures so first we're going to talk about hollow and solid organs so the hollow organs of the abdomen include the stomach intestines ureter and bladder and when ruptured or lacerated the contents spill into the peritoneal cavity causing inflammation and possible infection and we call this infection peritonitis severe abdominal pain tenderness and muscle spasms happen when you when the patient has peritonitis intestinal blood supply comes from the mesotenary it's a fold of tissue that\nconnects the small intestines to the abdominal wall patients with injuries to the mesotenary can bleed significantly into the peritoneal cavity signs of this include abdominal rigidity and periumbilical bruising so these figures show the hollow and the solid organs of the abdomen\nthe solid organs of the abdomen include the liver spleen pancreas and kidneys these organs perform the chemical work of the body which include enzyme production blood cleansing endocrine function and energy production because of the rich blood supply hemorrhage of the solid organs can be severe now the retroperitos peritoneal space is the posterior aspect of the abdomen and behind the peritoneum this includes the kidneys ureters urinary bladder and the majority of the pancreas",
        "Injuries to the Abdomen": "so let's talk about injuries to the abdomen abdominal injuries are considered either open or closed and can involve solid or solid organs closed abdominal injuries can be from blood trauma to the abdomen so there's many mechanisms of injury that are capable of causing closed injuries they could include motor vehicle crashes motorcycle crashes falls blast injuries pedestrian versus bicycles rapid deceleration or compression injuries they may initially appear as abrasions on the surface of the skin and it may take several hours for the contusion or hematoma to become more visible you could have injuries from seatbelts and",
        "Closed Abdominal Injuries": "airbags and when worn properly the seatbelt lies below the anterior superior iliac spine of the pelvis and against the hip joints if the bulb is too high it can squeeze the abdominal organs or create vessels against the spine when the car decelerates or stops and can also cause can cause bladder injuries in pregnant patients who adjust the lap belt for comfort so remember to inspect beneath the airbag for signs and damage to the steering column so this figure shows the correct and correct placement of the seat belts next we're going to talk about open abdominal injuries and so injuries in which a foreign object enters the abdomen and opens the peritoneal cavity to the outside open wounds can be deceiving therefore you should maintain a high index of suspicion for unseen injuries internal damage to organs and potential life-threatening injuries so there's three different types of velocity injuries and we're going to talk about those next so the velocity of an object can help predict the amount of damage to the tissue low velocity injuries caused by hand-held or hand powered objects such as knives or other edged weapons then you have medium velocity injuries and this can caused by small caliber handguns and shotguns then there's high caliber and that's caused by larger weapons such as high powered rifles or higher powered handguns high and medium velocity injuries have temporary wounds channels in addition to exit and entrance wounds cavitation occurs as the pressure away from the projectile is transferred to the tissues the higher the velocity of the projectile the larger the cavity it produces and then when you talk about low velocity penetrations also have a capacity to damage underlying organs internal injury may not be as apparent during the physical exam and any time a patient has an injury at or below the zyphoid process it should be assumed that the thoracic and peritoneal cavities have been violated when it comes to an evisceration bowel protrudes from the peritoneum it can be extremely painful and also visually shocking do not push on the patient's abdomen only perform a visual assessment when there is any suspicion of this type of injury cut clothing close to the wound and never pull on any clothing stuck to or in the wound channel",
        "Hollow Organ Injuries": "when you talk about hollow organs they often have delayed signs and symptoms commonly they spill the contents into the abdomen infection develops and that may take hours or days\nboth blunt and penetrating trauma can cause hollow organ injuries blood trauma causes the organ to pop and this releases fluids and air and penetrating trauma causes a direct injury such as lacerations or punctures the gallbladder and urinary bladder are hollow organs whose contents are potentially irritating and damaging if ruptured these fluids move loose spaces and voids in the peritoneal cavity eventually leading to infection free air in the peritoneal cavity produces pain usually this indicates that a hollow organ or loop of the bowel has been perforated if not rapidly identified or repaired several infections of severe infections and septic shock may develop let's talk about the solid organ injuries so we talked we said solid organs can bleed significantly and cause rapid blood loss and like we said earlier it's hard to identify and so because the patient is not experiencing that much pain so solid organs can also ooze blood into that peritoneal cavity and this causes pain to increase slowly over time the liver is one of the largest organs in the abdomen it's very vascular and can contribute to hypoperfusion if injured often injured by a fractured lowered rib lower rib and or penetrating trauma common assessment findings is referred pain to that right shoulder the spleen and the pancreas are also very vascular both are prone to heavy bleeding when fractured lacerated or punctured referred left shoulder pain also occurs in some cases of splenectic injury the diaphragm is penetrated or ruptured loops of the bowel may herniate through the thoracic cavity the patient is going to have some dipsnia and change in position from upright to supine in a more abdominal can cause more abdominal contents to spill into that thoracic cavity and this could compress the lungs prohibiting the lungs from fully expanding the kidneys can also be impacted or penetrated by trauma this can cause significant amounts of blood loss common findings is blood in the urine hematuria and blood visible on inspection of the urinary miatis indicates significant trauma in the genituria system",
        "Patient Assessment of Abdominal Injuries": "so let's do the patient assessment of these abdominal injuries okay so assessment findings in patients with potential abdominal injuries can be challenging to interrupt some are obvious however many are easily overlooked patients with patients may be overwhelmed with more painful injuries and some abdominal injuries develop or worsen over time",
        "Scene Size-up": "so of course we're going to start that patient assessment with the scene size up and we have to be sure that the scene is safe we need to call for additional resources early if we need them the moi and noi we have to consider early spinal precautions and consider all of the injuries of that mechanism of injury and what they could be produced",
        "Primary Assessment": "then we're going to do the primary assessment we have to quickly form that general impression and note the patient's level of consciousness severe external hemorrhage may be addressed before airway and breathing concerns ensure the patient has a clear and patent airway and then there's circulation we need to treat signs and symptoms of shock aggressively and transport decisions so patients with that abdominal injury should be evaluated at the highest level of a trauma center if available\nso your primary assessment you're going to quickly scan the patient and also injuries can produce a significant amount of volume of blood so do not avoid this area in the rapid scan if bleeding is present you have to maintain privacy of course control severe bleeding first ensure the patient has a clear and paid patent airway provide assessment ventilations with the bag valve mask as needed and consider the need for spinal motion restriction when it comes to circulation we're going to do the pulse rate skin condition color temperature and cap refill clothes injuries do not do not have visible signs of bleeding so treat for signs of shock and note the patient's level of alertness transport decision we want to make sure we transport to a trauma center then we're going to do that history taking and we're going to investigate the chief complaint common associated complaints with genital urinary injuries are nausea and vomiting diarrhea blood in the urine vomiting blood and abnormal bowel or bladder habits the sample history so you use the opqrst and ask the patient about output especially blood in the urine ask about allergies to medications or environmental triggers repeat uh repeated or previous injuries or illnesses can help determine the extent of the current in injury or illness the last food intake in fluids are important because it can predict the genital urinary system's contents and then address the events leading up to the injury when it comes to the secondary assessment there are times when you will be unable to conduct this conduct this the need to provide ongoing life-saving treatment and transport time will keep you from doing that secondary assessment so when the patient has an isolated injury focus on that and the body region affected assess for decaf btls and obtain the patient's vital signs and reassess frequency then your reassessment repeat the primary assessment vital signs reassess the interventions and treatment you provided adjust interventions as necessary and of course communication and documentation and your concerns to the hospital staff and then describe all injuries and treatments given when it comes to care of specific injuries",
        "History Taking": "next of course is the history taking of our assessment we need to do the sample history and the opqrst which is the history of the current illness we have to ask the patient if they're experiencing any nausea vomiting or diarrhea ask them about the appearance of any bowel movements and urinary output ask about referred pain peritonitis can cause pain provoked by removal of pressure and we call this rebound tenderness and guarding occurs when the patient tenses up or stiffens his or her abdominal muscles",
        "Secondary Assessment 1": "so our secondary assessment may not have the time to perform this of course in the field and but physical exams you want to make sure that you remove loosened clothes to expose any injured bodies regions of the body and transport the patient in the con the position of comfort unless of course spinal injury is suspected examine the entire abdomen including all posterior anterior and lateral surfaces and then we're going to use d-cap btls to help identify specific signs and symptoms of injuries we want to palpate the abdomen when examining the region palpate the quadrant farthest away from that from the quadrant that is experiencing signs and symptoms of injury and pain and perform a full body scan to identify injuries other than abdominal injuries inspect and palpate the kidney area for tenderness bruising swelling or other signs of trauma and then is vital signs so we have to obtain and record vital signs early and we need to repeat them every five minutes in patients who we suspect have a serious injury hypotension is a late sign of shock",
        "Assessment of an Isolated Abdominal Injury": "okay and so with those isolated abdominal injuries we're going to visually inspect the abdomen for penetrating wounds if an entrance wound is found check for the corresponding exit wound do not remove an impaled object",
        "Reassessment": "in our reassessment we want to repeat the primary and vital signs reassess the interventions and treatment you have provided and communication and documentation outline the patient's mechanism of injury injuries and relevant vital signs all right so let's talk specifically about emergency care of abdominal",
        "Emergency Medical Care of Abdominal Injuries": "injuries when it comes to close abdominal injuries we want to monitor the patient closely to evaluate for progression into shock the patient may experience nausea and vomiting have suction available administer oxygen to patients who are unconscious or who are in shock keep the patient warm assist ventilations if necessary and consider calling advanced life support for placement of an oral or nasogastric tube and then there's the open abdominal injuries patients with penetrating injuries generally obvious wounds and external bleeding however significant external bleeding is not always present so maintain a high index of specific suspicion for serious unseen blood loss then follow the general\nprocedures described previously for care of blood abdominal injury as well as inspect the patient's back and sides for the exit wound apply a dry sterile dressing to all open wounds and if the penetrating object is still in place apply a stabilizing bandage around it to control external bleeding and to minimize movement of that object so severe lacerations of the abdominal wall may result in what's called an evisceration an evisceration is basically fat or internal organs protruding from the wound you want to place a sterile dressing moist and with saline over the wound and apply bandage and transport never try to replace the protruding injury and keep the affected area warm okay so the figure shows the steps to apply a dressing to have abdominal injury",
        "Anatomy of the Genitourinary System": "now we're going to talk about the anatomy of the genital urinary system okay the genitourinary system controls reproductive functions and waste discharge organs of the genitourinary system are located in the abdomen and kidneys are the solid organs and the ureter's bladder and urethra are the hollow organs male and genit malgenitalia lie outside the pelvic cavity except for the prostate gland and seminal vesicles okay the female genitalia genitalia are located entirely within the pelvis except the vulva clitoris and labia the figure shows the organs of the male reproductive system and then this figure shows the organs of the female reproductive system injuries to the system so let's talk about the kidney injuries not commonly and rarely occur in isolation meaning a force blow or penetrating injury is often involved unless significant injuries can result from an indirect blow such as a football tackle we want to suspect kidney damage if the patient has a history or physical evidence of any of the following so an abrasion laceration or contusion in that flank area okay and so the flanks are the the sides of the lower back and a penetrating wound in the region of the lower rib cage and above the hip or flank or the upper abdomen fractures on either side of the lower rib cage or the lower thoracic or abdominal upper lumbar vertebrae a hematoma in the flank region is also evidence of perhaps kidney damage",
        "Injuries of the Genitourinary System": "now let's talk about urinary bladder injuries and they may result in a rupture so urine would spill into the surrounding tissues blunt injuries to the lower abdomen or pelvis can cause a rupture to that urinary bladder particularly when the bladder is full and distended penetrating wounds of the lower mid abdomen or perineum can directly result in urinary urinary bladder injuries so in males sudden deceleration from a motor vehicle or motorcycle crash can shear the bladder from the urethra in later trimesters of pregnancy bladder injuries increase from displacement of the ureters the figure shows how a fracture of the pelvis can result in perforation of the bladder so when it comes to external genitalia injuries soft tissue wounds can be painful and of great concern to the patient but rarely life-threatening okay and they should not be given priority over more severe wounds unless there is significant bleeding pain may be referred to the lower abdomen with these injuries when it comes to female genitalia injuries internal female genitalia the uterus ovaries and fallopian tubes are rarely damaged they're small deep in the pelvis and well protected exceptions is when the female is pregnant okay so uterus enlarges substantially and rises out of the pelvis injuries can be serious because the uterus has a rich blood supply during pregnancy and also keep the fetus in mind external genitalia injuries so this can it includes vulva clitoris and the major and minor labia at the entrance of the vagina they have a rich nerve supply so injuries are painful and we want to consider sexual assault and pregnancy so ask the patient about the last known menstrual period and ask about sexual history assume all women of child bearing age are possibly pregnant in cases of external bleeding and trauma a sterile absorbent sanitary napkin or pad may be applied to the labia do not insert instruments glove finger or a tampon into the vagina",
        "Patient Assessment of the Genitourinary System": "all right so let's talk about the patient assessment in these injuries potential for patient embarrassment occurs so we have to maintain professional presence provide privacy and when possible we want to have an emt of the same gender perform the assessment scene size up so we have to assess foreseen hazards and threats to the crew apply standard precautions and look for indicators of the mechanism of injury patients may avoid the discussion to avoid undergoing the a physical exam and patients may also provide an mechanism of injury that seems less embarrassing than the actual mechanism",
        "Emergency Medical Care of Genitourinary Injuries": "first we're going to talk about kidneys so damage may not be obvious upon inspections you may see signs of shock or blood in the urine so treat for shock transport promptly and monitor vital signs and route to the hospital all right so injury to the urinary bladder we have to suspect a urinary bladder injury if we see any blood in the urethra opening or signs of trauma to the lower abdomen pelvis or peritoneum if shock or associated injuries are present transport promptly and monitor the vital signs and route then if we have any external male genitalia injuries a few general rules for the treatment of injuries to the external genitalia apply injuries are painful they make the patient uncomfortable so use sterile moist compresses to cover the areas stripped of skin apply direct pressure with dry sterile gauze to control bleeding and never move or manipulate foreign objects in their urethra identify and take evolved parts to the hospital with the patient if the patient has an evulsion of the skin on the penis wrap the penis in a soft sterile dressing moistened with sterile saline transport promptly and use direct pressure to control any bleeding try to save the and preserve that skin if you have an amputation of the penile shaft managing blood loss is the top priority use local pressure with a sterile dressing on the remaining stump never apply a constricting device and surgical reconstruction as possible if you can locate the amputated part wrap that part in moist sterile dressing place it in the bag and transport it in a cool container without it directly touching ice if the connective tissue surrounding that tissue is severely damaged the shaft can be fractured or severely angulated sometimes injuries can require surgical repair so associated with intense pain bleeding into tissues is the fear accidental laceration of the head of the penis is associated with heavy bleeding local pressure with sterile dressing usually stops the hemorrhage and then skin or shaft or foreskin can get caught in the zipper if a small segment of the zipper is involved you could cut the pants if a larger segment is involved use heavy scissors to cut the zipper out of the pants then urethra injuries in the male are not very common so lacerations of the urethra can result though with straddle injuries pelvic fractures or penetrating rooms of the peritoneum it is important to know if the patient can urinate or if there's blood in the urine so save any urination for later examination at the hospital any foreign bodies protruding from the urethra wall will have to be surgically removed a bulging of skin of the scrotum may damage the contents so preserve the evolved skin in a moist sterile dressing for possible use for reconstruction wrap the scrotal contents in um or in the perineal wall area with a moist compress and use local pressure dressings to control bleeding direct blows to the scrotum may result in a rupture of the testicle and significant accumulation of blood around the testes so apply ice pack to the scrotal area during transport then there's female genitalia injuries so treat lacerations abrasions or avulsions with moist sterile compresses use local pressure to control bleeding or hold dressings in place with a diaper type bandage do not place any dressings into the vagina leave any foreign objects in place after stabilizing it with bandages injuries are painful but generally not life-threatening in hospital evaluations is required so transport urgency in determined by associated injuries and the amount of hemorrhage and the presence of shock\nwhen it comes to rectal bleeding that's a common complaint possible causes include sexual assault foreign bodies hemorrhoids or ulcers in the digestive tract significant rectal bleeding can occur after hemorrhoid surgery and then next we're going to talk about sexual assault so assault um and rapes are all too common victims are generally women and sometimes men and children are victims often there is little you can do beyond providing compassion and transport the patient may have sustained multi-system trauma and need treatment for shock do not examine unless obvious bleeding requires application of a dressing follow appropriate protocols and procedures shield the patient from curious onlookers and document the patient's history assessment treatment and response to the treatment for possible court appearances follow any crime scene policy of your ems system you want to advise the patient not to wash bathe shower douche urinate or defecate until after physical exam if oral penetration occurred advise the patient not to eat drink brush the teeth or use mouthwash until after the exam handle the patient's clothes as little as possible and place the articles of clothing or other evidence in paper bags do not use plastic bags because mold can grow and destroy the evidence make sure the emt caring for the patient is of the same gender as a patient whenever possible treat medical injuries and provide privacy support and reassurance",
        "Review": "okay so that concludes chapter 31 of the genital urinary injuries now we're going to go through the review questions to see what we've learned all right so peritonitis would most likely result from which of the following injuries it's going to be d remember it's the hollow organs that spill their contents that are going to cause the peritonitis the stomach is the hollow organ which of the following organs would be most likely to bleed profusely if severely injured well we know that the liver which is the largest organ in the stomach or in the at that abdominal area and it's a solid right so approximately 40 percent of the total blood volume at any given time is in the liver which of the following statements regarding intra abdominal bleeding is false so see intra-abdominal bleeding is commonly common following the blood trauma to the abdomen the absence of pain and tenderness rules out intra-abdominal bleeding when seat belts are worn properly and airbags deploy injury may occur to the and we know that's the iliadic crest because that's where the seatbelt is worn when inspecting the interior of the wrecked automobile you should be most suspicious that the driver experienced an abdominal injury if you find and we know that's the deformed steering wheel other than applying moist sterile dressing covered with a dry dressing to treat abdominal evisceration an alternative form of management may include and it's going to be d and that is applying occlusive dressing secured by trauma dressings you're transporting a patient with possible peritonitis following trauma to the abdomen which position would most likely prefer to assumed and we know that this is probably with the legs drawn up of course if there's no trauma suspected legs drawn up a 16 year old boy was playing football and was struck in the left flank during a tackle his vital signs are stable however he has a lot of pain you should be most concerned with his injury too and we know that's the kidney the flanks the term hematuria is defined as and we know that this is blood in the urine hema blood and then urine urea okay when caring for a female with trauma to the external genitalia the mt should and we know that there is a just local um some type of local pressure can usually control the bleeding okay thank you for um going over chapter 31 with us today if you've liked this lecture go ahead and subscribe to the channel thank you"
    },
    {
        "Introduction": "hello and welcome to chapter 30 chest injuries of the emergency care and transportation of the sick and injured 12th edition",
        "National EMS Education Standard Competencies": "after you complete this chapter and the related coursework you will understand how to manage a patient with chest trauma you will learn how to recognize life threats associated with these injuries and how to provide immediate intervention the curriculum includes a detailed description of the anatomy and physiology of the chest and underlying organs as well as the pathophysiology complications assessment and management of chest injury age-related issues are discussed specific to pediatric and geriatric trauma this chapter also provides information on incidents including morbidity and mortality and a detailed discussion of blunt versus penetrating and open trauma specific injuries discussed include sucking chest wounds pneumothorax tension pneumothorax hemothorax flailed chest and pericardial tamponade",
        "Introduction to Chest Trauma": "so let's get started chest trauma causes more than 1.2 million emergency department visits each year injuries can involve the heart lungs and great vessels may be a result of blunt trauma penetrating trauma or both emts must treat any injuries that interfere with the body's mechanisms of normal breathing without delay internal bleeding can collect in the chest cavity compressing the heart and lungs an air may collect in the chest and prevent the lungs from expanding",
        "Anatomy and Physiology": "let's talk a little bit about the anatomy and physiology remember the difference between ventilation and oxygenation ventilation is the body's ability to move air in and out of the chest and lung tissue oxygenation is the process of delivering oxygen in the blood by diffusion from the alveoli following inhalation into the lungs injuries affecting the patient's ventilation and oxygenation are serious and may be life-threatening the chest otherwise known as the thoracic cage extends from the lower end of the neck to the diaphragm a penetrating injury to the chest may also penetrate the lung and diaphragm and injure the liver spleen or stomach thoracic skin muscle and bones have similarities to skin muscle and bones",
        "Anatomy and Physiology Continued": "and other regions of the body unique features such as striated or skeletal muscle allow for ventilation okay so intercostal muscles extend between ribs and these are not yet developed in very young children who tend to breathe from the diaphragm this is also known as belly breathing they're inverted from the spinal nerves and they allow the chest to expand on contraction and the active portion of ventilation to occur the neurovascular bundle is a network of nerves arteries and veins lying closely along the inferior of and slightly posterior to the longest margin of each rib it can be a source of significant bleeding into the pleural space the pleura covers each of the lungs and",
        "Thoracic Cavity and Ventilation": "the thoracic cavity the parental pleura is the inner lining of the chest wall and the visceral pleura covers the lung a small amount of pleural fluid between the parential and the visceral pleura allows the lungs to move freely against the inner chest wall as a person breathes the ribs are connected in the back to the vertebrae and in the front to the sternum the trachea divides into the left and right mean bronchi stem bronchi which supply air to the lungs the thoracic cage contains the heart and the great vessels the aorta the right and left subclavian arteries and their branches the pulmonary arteries and the superior and inferior vena cava the mediastinum is the central part of the chest containing the heart great vessels esophagus and trachea the diaphragm is a muscle that separates the thoracic cavity from the abdominal cavity so let's talk about the mechanics of ventilation the intercostal muscles and",
        "Mechanics of Ventilation": "that's between the ribs contract during inhalation the diaphragm contracts or flattens at the same time the inner thoracic pressure inside the chest decreases creating a negative pressure differential allowing air into the lungs the intercostal muscles and diaphragms relax during exhalation allowing air to be exhaled the illustration on this slide shows the anatomy of the thoracic cavity during inspiration and expiration",
        "Spinal Injuries and Ventilation": "a patient whose spinal cord is injured below c5 may lose the power to move the intercostal muscles the diaphragm should still contract the patient will still be able to breathe because of the phrenic nerves remain intact and the patients with a spinal injury at c3 or above can lose the ability to breathe entirely tidal volume is the amount of air moved into or out of the lungs in each single breath the average tidal volume is approximately 500 milliliters minute volume is calculated by multiplying the tidal volume by the number of breaths in a minute changing either of these numbers affects the amount of air moving through the system the average bag mass device can deliver 1000 to 1500 milliliters of air over ventilation can cause gastric distension and impair lung function over ventilation can also increase intrathoracic pressure reducing venous return to the heart and thereby reducing cardiac output",
        "Types of Chest Injuries": "injuries to the chest there are two basic types of chest injuries and these are open or closed in chest injuries closed chest injuries the skin is not broken they are generally caused by blunt trauma they often cause significant contusions in cardiac muscle or otherwise known as a cardiac contusion and lung tissue and this is a pulmonary contusion if the heart is damaged it may not be able to refill with blood or blood may not be able to be pumped with enough force out of the heart this results in cardiogenic shock lung tissue bruising can result in exponential loss of surface area it could lead to decreased oxygen and carbon dioxide exchange and it can cause hypoxic and over hypercarbic states rib fractures can lacerate lung tissues and cause further vessel damage with every chest wall movement and it can rapidly lead to hypovolemic shock in an open chest injury an object penetrates the chest wall itself this causes instant damage but symptoms develop over time an impelled object remains in place do not attempt to move or remove an object may be occluding a hole in a punctual vessel removing it would cause heavy bleeding and it may cause damage during the removal blunt trauma to the chest may fracture the ribs sternum and chest wall bruise the lungs and the heart and even damage the aorta almost one-third of the people killed immediately in car crashes die as a result of penetrating rupture of the aorta signs and symptoms of a chest injury include pain at the site of the injury pain localized at the site of the injury that is aggravated or increased with breathing bruising to the chest wall crepitus with palpation of the chest or any penetrating injury to the chest or dipsnia failure of one or both sides of the chest expand normally with inspiration rapid weak pulse and low blood pressure cyanosis around the lips or fingernails diminished breath sounds on one side or low oxygen saturation patients with chest injuries often have tachypnea and this is rapid respirations and shallow restorations because it hurts to take a deep breath",
        "Scene Size-up": "so let's begin our patient assessment scene size up of course scene safety and standard precautions are important if the area is a crime scene do not disturb the evidence if possible request the assistance of law enforcement for scans or scenes involving violence if needed call for electrical utility fire department and advanced life support units early determine the mechanism of injury chest injuries are common in motor vehicle crashes falls industrial accidents and assaults determine the number of patients and consider spinal stabilization okay then you're going to form your",
        "Primary Assessment": "primary assessment within that primary assessment is that general impression and you want to look for life-threatening hemorrhaging when present and it should be addressed immediately even before airway concerns note the patient's level of consciousness and perform a rapid physical exam",
        "Airway and Breathing Assessment": "then it's the a and the b and then the c so let's do the a and the b first airway and breathing ensure that the patient has a clear and patent airway consider early cervical spinalization with blood trauma okay so note whether the jugular veins are distension they're distended and this is a sign of pressure on the heart determine whether breathing is present and adequate and inspect for dcap btls look for equal expansion of the chest wall check for paradoxical motion and an abnormality associated with multiple fractured ribs apply an exclusive dressing to all penetrating injuries to the chest apply oxygen with a non re breather at 15 liters and provide positive pressure ventilation at 100 percent if breathing is inadequate be alert for decreasing oxygen saturation be alert for signs of impending tension pneumothorax next we're going to talk about circulation so assess the pulse and determine whether it is present and adequate if the pulse is too fast or too slow or if the skin is pale cool or clammy consider the patient to be in shock and then address life-threatening external bleeding immediately transport decision so priority transports are those who have a problem with their airway breathing or circulation so pay attention to subtle clues appearance of the skin the level of consciousness a sense of impending doom in the patient and when in doubt transport the patient rapidly to the hospital table 31 lists the deadly dozen chest injuries okay so on this table it lists those injuries",
        "History Taking": "okay next is going to be your history taking so investigate that chief complaint further investigate the mechanism of injury and identify associated signs and symptoms and pertinent negatives questions should focus on the mechanism of injury speed of the vehicle or height of the fall use of safety equipment type of weapon number of penetrating wounds and then get your sample history and complete a basic evaluation if time allows",
        "Secondary Assessment": "then we have that secondary assessment so for trauma we're going to do a physical exam for an isolated injury of course we're going to focus on that isolated injury or the patient's chief complaint or the body reason of body region affected ensure wounds are identified and bleeding is controlled locate and the extent of the injury assessment of all underlying systems anterior and posterior aspects of the chest wall and changes in the patient's ability to maintain adequate respirations for significant trauma likely affecting multi-systems start with a rapid physical exam and use dcap btls to determine the nature and extent of the thoracic injury then vital signs so assess pulse respiration blood pressure skin condition oxygen saturation and pupils re-evaluate the patient every five minutes or less a rapid pulse or respiratory rate may indicate that the chest injury is causing a decrease in available oxygen or hypoxia or blood loss resulting in decreased red blood cells increased work of breathing may be identified by the use of accessory muscles in the face neck and chest and pulse and respiratory rates may decrease in later stages of the chest injury",
        "Reassessment": "you want to recess mint so you want to repeat the primary assessment reassess the chief complaint re-evaluate airway breathing pulse perfusion and bleeding and then your interventions so reassess vital signs and observe trends provide appropriate spinal mobilization for patients who have blunt trauma with suspected spinal injuries maintain an open airway roll significant visible bleeding and place a vented chest seal or semi-vented dressing over penetrating trauma to the chest wall provide aggressive treatment for shock and transport rapidly do not delay transport to complete non-life-saving treatments these can be performed and route to the hospital and then of course communicate all relevant information to the staff at the receiving facility",
        "Pneumothorax": "complications and management of chest injuries so first we're going to talk about a pneumothorax okay so a pneumothorax is defined as accumulation of air in the pleural space air enters through a hole in the chest wall or surface of the lung the patient's attempts to breathe causes the lung in or on the side to collapse blood passing through the collapse portion of the lung is not oxygenated breath sounds on the affected side of the chest indicate different conditions okay so if the lung has collapsed past 30 to 40 percent you may hear diminished breath sounds absent breath sounds may indicate a tension pneumo and a sucking sound on inhalation and the sound of rushing air on exhalation indicate that the chest has been penetrated okay so the illustration on this slide shows how a pneumothorax occurs air leaks into the space between the pleural surface from an opening in the chest wall or the surface of the lung and then air in the pleural space causes the lung to collapse an open chest wound is often called an open pneumothorax or sucking chest wound after cleaning and make or clearing and maintaining the patient's airway and then providing oxygen these wounds must be rapidly sealed with an occlusive dressing a flutter valve is a one-way valve that allows air to leave the chest cavity but not to return follow local protocols and the manufacturer's guidelines an occlusive dressing without a flutter valve may be taped on the patient on three sides of the dressing allow air to leak from the foresight apply after applying the dressing carefully monitor the patient for the signs of the tension pneumo if it develops open the occlusive dressing on one side the illustration on this slide shows a sucking chest wound the air passes from the outside into the pleural space and back out with each breath creating a sucking sound and then you have a simple simple pneumothorax it does not result in major changes in the patient's cardiac physiology commonly the result of blood chest trauma that results in fractured ribs signs and symptoms include pleuratic pain dyspnea tachypnea accessory muscle use decreased oxygen set and a cracking sensation felt on palpation of the skin and this is subcutaneous emphysema late findings can be decreased breast sounds on the injured side as well as lethargy and cyanosis so pre-hospital treatment for this you want to provide high flow to and monitor oxygen readings and breath sounds then you have a tension pneumo so this results from ongoing air accumulation in the pleural space this rat this air gradually increases the pressure in the chest causing complete collapse of the uninfected lung mediastinum is pushed into the opposite pleural cavity more commonly caused by blunt trauma in which a fractured rib lacerates a lung or bronchus common signs and symptoms include chest pain tachycardia marked respiratory distress low or rapidly dropping oxygen sad and absent or severely decreased lung sounds on the affected side with lung sounds or with signs of shock the patient may also present with jvd cyanosis or tracheal deviation but these signs are not always present pre-hospital treatment includes support ventilation with high flow oxygen request advanced life support and transport immediately needle decompression may be performed by advanced life support personnel or emergency department staff depending on local protocols so the illustration on this slide shows a tension pneumothorax",
        "Hemothorax": "then we're going to talk about now we're going to talk about hemothorax so this is a condition in which blood collects in the pleural space from bleeding around the rib cage or from a lung or grave vessel and so what you see that on this slide is a hemothorax or a hemo-pneumothorax a hemothorax is a collection of blood in the plural space produced by bleeding into the chest wall or within the chest wall when both blood and air are present the condition is called a hemo pneumo suspect a hemothorax if the patient has signs and symptoms of shock without any obvious external bleeding or decreased breast sounds on the affected side pre-hospital treatment include bleeding cannot be controlled in the pre-hospital setting provide rapid transport to the nearest facility capable of performing surgery the presence of air and blood in the plot space is known as a hemo pneumothorax",
        "Cardiac Tamponade": "cardiac tamponades the next one we're going to talk about and this is car also known as pericardial tampon and it occurs when pericardial sac fills with blood or fluid now that results in the part not being able to pump an adequate amount of blood so this illustration shows cardiac tamponade and with cardiac tamponade fluid builds up in the pericardial sac causing compression of the heart's chambers and dramatically impairing its ability to pump blood to the body signs and symptoms are referred to as the bex triad and include distended or engorged jugular veins on both sides of the trachea and narrowing pulse pressures and muffled heart tones pre-hospital treatment and core includes supporting ventilations and rapidly transporting the patient to the facility capable of intervention",
        "Rib Fractures": "and then you have rib fractures so they're common particularly in older patients whose bones are brittle a fracture of one of the upper four ribs is a sign of a substantial mechanism of injury a fractured rib may lacerate the surface of the lung causing a pneumothorax attention pneumothorax hemothorax or a hemopneumothorax patients with one or more cracked ribs will report localized tenderness and pain when breathing pre-hospital treatment includes supplemental oxygen",
        "Flail Chest": "then you have a flailed chest so this is caused by two or more adjacent fractures in two or more places causing a segment of the chest wall to detach from the rest of the thoracic cage the deta attached portion of the chest wall moves possible or normal which is called paradoxical motion paradoxical motion is a late sign of a flail segment pre-hospital treatment of a flailed chest includes maintaining the airway providing respiratory support if needed giving supplemental oxygen and perform ongoing assessments for possible pneumothorax or other respiratory complications treatment may also include positive pressure ventilation with a bag valve mask restricting chest wall movements such as splinting the flailed chest with a bulky dressing and is no longer recommended flail chest may indicate serious internal damage and possible spinal injury",
        "Other Chest Injuries": "then we're gonna now we're gonna talk about other chest injuries so you could have a pulmonary contusion and this should be suspected in a patient with a flailed chest the pulmonary alveoli become filled with blood and the fluid accumulates in the injured area leaving the patient hypoxic okay pre-hospital treatment includes providing supplemental oxygen and positive pressure ventilations as needed to ensure adequate oxygenation and ventilation and then other fractures so you could have sternal fractures and this requires a significant amount of force it may involve the lungs great vessels and the heart you could also have clavicle fractures and also significant damage or disruption to the large neurovascular bundle that the clavicle protects is possible suspect upper rib fractures in the medial clavicle fractures be alert to possible signs of a hemothorax which could develop then there's traumatic asphyxia so this is a severe compression of the chest which produces a rapid increase in pressure within that chest it's characterized by distended neck veins cyanosis to the face and neck or hemorrhage into the sclera of the eyes this suggests underlying injury to the heart and possibly pulmonary contusions pre-hospital treatment includes providing ventilatory support with supplemental oxygen monitors the signs during immediate transport we're going to talk about kamado cortis and this is a blunt chest injury caused by a sudden direct blow to the chest that occurs only during the critical portion of the person's heartbeat and what this will do is it will result in immediate cardiac arrest the result is of ventricular fibrillation is often responsive to defibrillation and early initiation of cpr okay so more commonly associated with sports related injuries but should be suspected in all cases in which the person is unconscious and unresponsive after a blow to the chest and then there could be laceration of great vessels so this may be accompanied by a massive fatally a rapidly fatal hemorrhage pre-hospital treatment of includes cpr ventilate ventilatory support with supplemental oxygen immediate transport and remain alert to signs and symptoms of shock closely monitor patients in baseline vital signs",
        "Review and Conclusion": "okay so that concludes chapter 30 a chest injuries lecture let's go through these uh review questions let's see how much we've learned okay so when the chest impacts the steering wheel during a motor vehicle crash with rapid deceleration the resulting injury that kills almost one-third of the patients usually within seconds is uh that's going to be an aortic shearing i don't think we talked much about that but um and aortic injuries or shearing are caused of the causes of death in nearly nearly one-third of patients the aorta is the largest artery in the body when it is sheared from its supporting structures um basically the patients bleed out within a matter of seconds signs and symptoms of a chest injury include all of the following except okay so that's going to be b hemoemesis okay so usually they're not vomiting blood okay during your assessment of the patient who has been stabbed you see an open wound to the left anterior chest your most immediate action should be cover the wound with an occlusive dressing so d cover that wound with an occlusive dressing when caring for a patient with a sign of a pneumothorax your most immediate concern should be okay we're going to worry about ventilatory inadequacy okay because that lung is involved so that is correct number five what purpose does a one-way flutter valve serve when the patient's when used on a patient with a pneumo so what it's going to do it's going to allow the release of air trapped in that pleural space okay so that's b won't let air in but it'll allow us to release it okay so signs of a cardiac tamponade include all of the following except so the bex triad which is muffled hard tones and narrowing pulse pressure and enlarged jugular veins not collapsed so we're going to say c is wrong and that is correct it is going to be distended check jugular veins okay so a patient experiencing a severe compression to the chest when trapped between a vehicle and a brick wall you suspect traumatic asphyxia due to a hemorrhage into the sclera of the eyes and which other sign which other sign i would think it would be cyanosis to the face and neck okay number eight a 14 year old baseball player was hit in the chest with a line drive he is in cardiac arrest well we know right away this is going to be kamado cortis kamato quartus paradoxical chest movement is typically seen in patients with and we know that that is going to be a flail chest paradoxical is flailed 40 year old man who was the unrestrained driver of a car that hit a tree at a high rate of speed struck the tree he start struck the steering wheel with his chest he has a large bruise over the sternum irregular pulse rate you should be most concerned with i would say an extensive bleeding into that pericardial sac oh and they're gonna say is that he injured his myocardium so i guess that's about the same thing but um a bruise to that myocardium okay all right so thank you very much for joining us tonight for chapter 30 chess injuries if you like this lecture go ahead and subscribe to the channel thanks"
    },
    {
        "National EMS Education Standard Competencies": "hello and welcome to chapter 32 the burns lecture although you probably won't see moderate or severe burns on a daily basis you will encounter some serious thermal burn injuries during your career and you might encounter serious electrical chemical and radiation injuries as well accurate recognition of the severity of the burn injuries can dramatically enhance the care of burn patients by allowing you to institute proper emergency care it is important to understand the treatment of burn shock in addition contacting and receiving the receiving facility in raw will allow burn specialists to provide triage over the phone and will allow them to prepare for the incoming patient okay so let's get started",
        "Introduction": "there are approximately 450 000 burn injuries which require medical attention each year bird injuries and death in the united states have decreased due to education and stricter building codes children younger than five years and elderly people are at higher risk the ability to treat large burns has improved due to better understanding of hypovolemic shock advantages and use of fluid therapy and antibiotic use of biologic dressing to aid early wound closure and the formation of specialized teams to treat patients death and injury also occur from electrical and chemical burns accurate recognition of the severity of injuries can enhance the care of patients and contacting the receiving facility and route will allow burn specialists to provide triage over the phone and prepare for the patient",
        "Anatomy and Physiology Review": "so let's talk a little bit about anatomy and physiology and do a little review first this human skin has a crucial role in maintaining homeostasis within the body the skin is usually able to repair itself there's four functions of the skin and it provides protection from the environment it regulates temperature and fluid and contains sensory nerves that communicate with the brain it also aids in healing and by responding to injury with inflammation people who survive serious burn injuries may have difficulty with thermoregulation and inability to sweat from the scarred portions of the skin an impaired vasoconstriction and vasodilation in the areas of damage little or no melon in the scar tissue and an inability to grow hair on the injured site little or no sensation in those scarred areas as well",
        "Layers of the Skin": "so there's layers of the skin remember the skin is composed of two principal layers there's the epidermis and that's the outermost layer it's the body's first line of defense in a major barrier against water dust microorganisms and mechanical stress it's also composed of several layers and then you have the inner layer which is the dermis and that's composed of collagen fibers elastin fibers and gel and there's a figure that shows the layers of the skin so enclosed within the dermis are several structures there are nerve endings and blood vessels and sweat glands and hair follicles and also sebaceous glands subcutaneous tissue is a thick layer of connective tissue located between the dermis and underlying muscle and bone it's also known as the superficial fossa it isolates protects and stores energy in the form of food of fat okay so this table shows the specialized structures of the dermis and then there's also the eye we're going to talk about the eye is sensitive to burn injuries tear ducts and islands eyelids constantly lubricate the surface of the eye and in heat intense heat light and chemical reactions can burn the thin membrane covering the surface of the eye the higher the ph of the substance the more severe the damage to the eye and the damage is worsened by rubbing the eyes as opposed to just irrigating them",
        "Pathophysiology": "so let's talk a little bit about pathophysiology next so soft tissue injuries the injuries are created by destructive energy transfer via radiation thermal or electrical energy when a person is burned the skin is damaged the victim becomes at high risk for infection hypothermia hypovolemia and shock",
        "Hypovolemic Shock": "so let's talk about the shock associated so hypovolemic shock occurs because two types of injuries so there's fluid loss across the damaged skin and then there's a series of volume shifts within the rest of the body so intravascular volume oozes into the interstitial spaces so cells of normal tissue taken increased amounts of salt and water from the fluid around them as blood pressure falls tachycardia and vasoconstriction occur chemical mediators are released and possibly causing additional damage now coagulation disorders may cause excessive bleeding it just depends on the nature of the burn and results in emboli or failure to clot and excessive bleeding so shock involves the entire body it limits the distribution of oxygen and glucose to those tissues and hampers the circulation's ability to remove the waste products inadequate fluid resuscitation is essential essential so you have thermal burns and they can occur when the skin is exposed to a temperature higher than 111 degrees fahrenheit it can also occur when the heat absorbed exceeds the tissue's capacity to dissipate it so there's a severity and it correlates with the temperature concentration amount of energy possessed by the object dur and the duration of exposure so thermal burns may also be more severe for patients trapped in an enclosed space with accumulating toxins the heat energy can be transmitted in a variety of ways there's flame burns and that's the most common it's often a deep burn and may also be associated with inhalation injuries their scald burns and they're produced by hot liquids often cover large surface area because liquids can spread quickly and approximately 5 000 skulled burns annually from spilled food and beverages then there's contact burn so these are produced by coming in contact with hot objects rarely deep because reflexes normally protect a person from prolonged exposure they may be a sign of abuse children or older people or people with disabilities and then there's steam burns and they can produce a topical school burn common when peeling away plastic wrapping covering microwave food the upper airway which is the supraglottic trauma from inhaled and hot gases rarely leads to subglottic burns and then there's flash burns they're a relatively rare source of thermal burns they're produced by an explosion injuries are usually minor compared with the potential for trauma from whatever caused the flash okay so burns are",
        "Burn Zones": "described by three pathogenic progressions or zones so there's a zone of coagulation and the skin is nearest to the heat source suffers the most profound cellular changes there's little or no blood flow to this area then there's the zone of stasis and that's the area surrounding the zone of coagulation has decreased blood flow and inflammation and it may undergo necrosis within 48 hours of the injury and then you have the zone of hyperemia so in this area skins will typically recover within seven to ten days",
        "Burn Depth": "so then there's the burn depth and that's the severity of the burns they're classified according to the depth they're superficial which is the first degree partial thickness that's the second and full thickness is third and additional categories such as fourth fifth and sixth degree burns they um uh there's no significant amount of time categorizing burns in the field so burns will look different in a few hours and so this figure shows the classification of burns according to the depth so superficial partial p partial thickness and full thickness okay superficial burns that's a superficial burn involves the epidermis only with a superficial burn the skin is red and swollen when touched the color will blanch and return patients will experience pain because nerve endings are exposed and the superficial burn will heal spontaneously within three to seven days it's the most common example um is a sunburn and then you have partial thickness burn this involves the epidermis and varying degrees of the dermis it can be sub um subdivided into moderate partial thickness burn and that's the red skin when touched the color will blanch and return it has blisters or moisture is present the patient may experience extreme pain hair follicles remain intact and the type of burn will typically heal spontaneously but a scar or have a some type of changed appearance then you have deep partial thickness burn that extends into the dermis and damages the hair follicle and sweat and subcutaneous glands so it may be difficult to distinguish between the two in the field and then you have the full thickness burns a full thickness burn involves destruction of both layers of skin the skin is incapable of self regeneration the skin may be appear white and waxy brown and leathery or charred no cap refill occurs because the capillaries are destroyed sensory neurons are destroyed and treatment will often require grafting and there's no there may be no pain in the full thickness area but significant pain in the surrounding areas",
        "Inhalation Burns and Intoxication": "okay so after the thermal burns we're going to talk about inhalation burns and intoxication so serious airway compromise the lungs and the airway may be irritated by heat or toxic chemicals and so damage to the vocal cords larynx and lower airway is often associated with steam or heart hot particulate matter damage to the upper airway is often associated with superheated gases so smoke and superheated gas inhalation the majority of deaths from fires are not caused directly by burns but rather a result of inhaled inhalation of toxic gases upper airway compromise and pulmonary injury firefighters protect themselves by wearing scbas anyone who is exposed to smoke from a fire may experience thermal burns to the airway hypoxia from lack of oxygen or tissue damage and toxic effects caused by chemicals in the smoke okay so carbon monoxide intoxication carbon monoxide or co evolves from incomplete combustion of carbon compounds the less efficient of the combustion process the more toxic the gases that may be created um so co may be emitted when furnaces kerosene heaters and other heating devices are in poor repair and co may also be admitted by internal combustion engines so this should always have their exhaust vented to the outdoors ceo can displace oxygen when the alveolar air and the blood hemoglobin so it binds to the receptor sites at least 250 times more easily than oxygen being exposed to relatively small concentrations will result in progressively longer blood levels of co and levels of 50 or higher may be fatal so co intoxication should be considered when a group of people in the same place all complain of a headache or nausea so people when they complain of feeling sick at home but not when they go to work or school so patients with severe co intoxication usually present with a co2 saturation of normal or better so never trust that pulse oximeter okay so now we're getting",
        "Patient Assessment": "into the patient assessment and there's possibly no signs of sickness the severity of injuries may not become apparent until you complete your assessment so initially stable conditions may be maybe deemed more serious after a careful evaluation at the hospital the progression of a burn related pathology pathology continues after the initial incident maintain a high index of suspicion even when injuries do not initially seem severe seriously burn patients may need to be transfer transferred from tertiary facilities to large burn centers and it is important to address burn patients in a consistent and systemic manner",
        "Scene Size-Up": "so there's the scene size up and safety is your primary concern whenever you are operating near a fire scene stage yourself in place where it is safe to provide patient care when a recently burned patient comes to you extinguish the flame and cool the burn do not permit a person whose clothing is on fire to run because flames it fans the flames have the patient stopped off and roll and remove all smoldering clothing remove any articles that may contain heat such as jewelry and if smoldering cloth adheres to the skin cut away instead of pulling at it that's the very first thing you want to do is remove the burning clothes so if possible determine the mechanism of injury and patients who have been burned may also have sustained other trauma so do not forget to wear appropriate personal protective equipment and follow your standard precautions",
        "Primary Survey": "next after the scene size up you know it's your primary survey so you want to get that general impression clues may help identify how serious injuries are more serious burns may present with little or no pain and the chief complaint is often i'm cold actually so uh recently burned patients may appear dazed or disconnected use compassion when approaching the patient focus on the abcs and patients with a burn injury may have varied mental status responses okay so combative patients should be considered hypoxic and isolated burns do not cause unresponsiveness remember that okay so airway and breathing so airway management is priority when it comes to a patient with a bird signs of airway involvement and a burn patient include harshness hoarseness cough strider singed nasal hair or facial hair facial burns or carbon in the sputum or a history of burn in an enclosed space okay remember that laryngeal edema can develop with alarming speed in early endotracheal innovation could be life-saving so to intervene early you need to spot the problem early listen the lung sounds pay attention to stridor and note if signs and symptoms of edema are present anyone suspected of having a burn to the upper airway may benefit from humidified cool o2 if you do not carry high output humidifier consider using an air size nebula nebulizer to administer normal saline and then circulation so during the first 24 to 48 hours of burn care fluid resuscitation is emphasized to prevent burn shock bird shock is a result of hypovolemia caused by fluid shifts that occur after the burn large volumes of fluid are not needed during the first minutes of pre-hospital care unless the injury occurred some time ago so do not delay transport by making multiple attempts at vascular access it's preferable to avoid starting iv lines through bird tissue interosseous access may provide you with more choices and then next we're going to talk about that burn severity so you want to evaluate the severity to determine which facility the patient should be transported to approximate the total body surface area or tbsa burned most practitioners advocate counting only the areas of partial and full thickness burns the universal method of calculating the burned area is the rule of nines divide the body into a leg 11 segments each accounting for one for nine percent of the body area at the proportions of the body that are burned to obtain the total of body area affected different rules applied to infants and children another method is the rule of palms and that's also known as the rule of ones so use the size of the patient's palm to represent one percent of the body's surface this is helpful when burns cover less than 10 of the body surface area or are irregularly shaped okay so there's another method and that's the lund browder chart and it divides the body into even smaller and more specific regions the american border association has also published burn severity classifications you could see those on this slide your transport decision so when it comes to your assessment the transport decision is going to be important you will need to estimate the burn size and severity to report to the receiving facility it's helpful for determining the appropriate destination and the care to be delivered patients with the following injury should be transferred to a burn specialty center or burn unit so partial thickness burns of more than 10 percent of the total body surface area burns that involve the face hands feet genitalia pernium or major joints full thickness burns in an age group electrical burns including lightning chemical burns or inhalation burns burns injuries in conjunction with pre-existing medical conditions that could complicate the management or prolong the recovery or affect the mortality so burns trauma in which the burn area poses the greatest risk of morbidity and mortality are burns to children in hospitals without qualified personnel and burn injury that requires special social emotional or long-term rehab so balance the need for accuracy against the time required to make the estimate of the total body surface area",
        "History Taking": "and then when it comes to the history taking of your assessment to the degree possible get a brief history of the patient patients with pre-existing disease may be triaged as critical even if the injury is small so allergies medications and other medical history may influence the patient's care",
        "Secondary Assessment": "and then you have your secondary assessment this is intended to make sure that no other injuries have higher priority for treatment pay attention to the circumstances of the burn and the possible mechanism of injury look for injuries to the eyes and if you find any cover the injured eyes with moist sterile pads and then you want to check for circumferential burns progressive edema beneath a circumferential burn may act as a tourniquet so if in the neck it may obstruct the airway if in the chest it's going to restrict breathing and if in an extremity it may cut off the circulation and put the extremity in jeopardy patients with circumferential burns must reach a medical facility quickly check and document distal pulses often and then of course obtaining vital signs may be challenging if the patient has extensive burns to the arms standard vital signs for a burn victim should include an assessment of blood pressure pulse oxygen saturation entitle and carb carb hemoglobin percentage so that's an spco percentage try to document vital signs accurately as a management of shock airway compromise and pain depends on them to some degree",
        "Reassessment": "when it comes to your reassessment you want to reassess vital signs every five minutes for critical and 15 minutes for low priority patients",
        "Emergency Medical Care": "okay so um what you're seeing on this slide is there is four phases of definitive burn care you have the initial evaluation and resuscitation the second phase is the initial wound excision and biologic closure then the third one is the definitive wound closure and then you have the rehabilitation and reconstruction it's measured in weeks not hours so burns not only cause physical trauma but they also impose the following types of burdens so emotional psychological and financial",
        "General Management": "so general management of that you should only turn your attention to the burn itself when the abcs are under control and you have all resuscitation equipment ready for use burn patients fall into four categories for airway morning management so you have patients with acutely decompensating airway who require field innovation and these patients include burn patients who are in cardiac or respiratory rest responsive patients who airways are swelling in front of you you need to plan for the possibility that you cannot innovate so surgical airways or rescue devices may be necessary patients with deteriorating airways from burns and toxic inhalations who might require innovation so for those patients it is better to defer treatment to the hospital teams attempt to innovate only if the patient's airway continues to swell and innovation will become impossible if you wait so try using a tube smaller than you would usually insert consult medical control for advice if there is significant time and the most experienced innovator should perform this procedure and select the largest endotracheal tube that will not cause additional trauma patients who airways are currently patent but who have a history of consistent with risk factors for eventual airway compromise so cool humidified o2 from a high output nebulizer is appropriate and report the patient's history to the hospital personnel patients with no sign or risk factors for airway compromise who are in no distress even if the patients are not in distress provide supplemental altitude to burn patients due to the potential for co poisoning and inaccuracy in pulse ox and the potential for airway compromise",
        "Fluid Resuscitation": "okay so next we're going to talk about something extremely important and this is for fluid resuscitation so fluid resuscitation is needed for patients with burns covering more than 20 percent of the tbsa if delayed for more than two hours from the time of burn mortality increases so begin to deliver an appropriate amount of fluid as soon as it is reasonable an iv line may be inserted in the field to administer fluids and for pain management try to get a large bore iv in a large vein and give lactated ringers solution if possible but do not delay transport to do so approximate the amount of fluid needed by using the con census formula so during the first 24 hours the patient will need two to four milliliters of lactated ringer solution multiplied by the patient's body weight in kilograms multiplied by the percentage of total surface body burned okay so half of the amount needs to be given during the first eight hours and the other will need to be given over the sub subsequent 16 hours you should not attempt to deliver the entire initial amount in the field giving fluid too early or too fast can lead to rapidly increasing peripheral edema monitor geriatric and pediatric patients for fluid overload carefully",
        "Pain Management": "okay so pain management assess the patient's pain before administering the analgesia reassessment should be completed using the same scale every five minutes burn patients may require high doses than usual to achieve relief because the metabolic the metabolism rates are accelerated pain medication is best given via iv absorption may be unpredictable in a burn patient as well so narcotic analgesics should be administered judiciously considers the factors when administering pain medications such as the site of the burn the presence of shock the concurrent illness or the patient's age and consult your protocols or contact medical control for guidance if needed next we're going to talk about hypovolemic shock so depending on the tbsa and depth of the burn involved you most likely will not see the presentation of hypoblaming shock if an acutely burned patient is in shock in the pre-hospital phase look for another injury as the same source",
        "Thermal Burns": "okay so with thermal burns considerations during your assessment is the presence or absence of pain swelling skin color cap refill time moisture and blisters appearance of the wound edges and presence of foreign bodies debris and contaminants bleeding and circulatory adequacy so cool small burn areas and large burn areas which are still hot and then apply dry sterile non-adherent dressing superficial burns can be very painful but rarely pose a threat to life if the patient is reached within the first hour after the injury occurred immerse the burned area in a cool water and apply a cold compress this stops the burning process and relieves the pain do not use salves or ointments cream sprays or any similar materials on the burn do not apply ice to the burn and transport the patient in a comfortable position to the hospital when it comes to partial thickness burns treatment in the field is similar to that of superficial burns you want to cool the burned area with water or apply wet dressings within the first hour elevate burned areas to minimize edema formation do not attempt to rupture the blisters and administer iv fluids and pain medication as dictated by your local protocol when it comes to full thickness burns pain assessment should be completed and pain medication administered dry dressings are often used begin fluid resuscitation preferably within two hours of the injury",
        "Thermal Inhalation Burns": "thermal inhalation burns you want to apply cool moist or aerosolized therapy to reduce minor edema aggressive airway management may be necessary if supraglottic tissues are swelling and they're threatening the patient's airway so heat inhalation may produce laryngospasms and bronchial spasms in the lower airway and later pulmonary involvement may be from toxic inhalation",
        "Chemical Burns of the Skin": "next we're going to talk about chemical burns so we just talked about the thermal burns and now we're going to talk about chemical burns so they occur when the skin comes in contact with strong acids alkaloids or bases or other corrosives the burning process as long as the substance remains in contact with skin will continue so typical management involves removal of the chemical solutions require copious amounts of flushing with water powders require you to draw to brush it off as much as possible before washing okay so the amount of damage depends on the chemical and the concentration and quality of the agent so the chemical state or temperature of the agent the length of duration and the depth of penetration they typically react with the skin and tissues quickly and in some cases the injury may take time to develop though when it comes to acid burns acid burns are relatively easy to neutralize acids cause destruction in coagulation of tissues results in coagulation necrosis that may actually limit the depth of the burn and alkali burns are more difficult to neutralize the effects are particularly pronounced in the eyes okay so let's talk about the uh patient assessment so begin by ensuring your own safety follow the decontamination of the patient consider wearing additional protective materials with management speed is essential so begin flushing the exposed area with copious amounts of water rapidly remove the patient's clothing have the patient bend over when washing the head to avoid chemicals running over the rest of the body wash the skin folds at joints and between fingers and toes and once washing is complete wash the body again after flushing keep the patient covered and warm there are several types of chemical burns require special management techniques and so dry lime that's a combination with water and when you combine it with water it will only produce highly corrosive substance so you want to remove the patient's clothing and brush away as much as you can make sure that you wear gloves yourself try to flush copious amounts with the garden hose or shower and then there's sodium metals so they produce considerable heat when mixed with water and may explode so cover the burn area with oil which will stop the reaction you have a hydrofluoric acid and burns that exceed three to five percent of the tbsa can be fatal pain will not improve even with copious amounts of flushing and calcium glucanamate gel is a preferred treatment so if it's not available then calcium chloride jelly may be used an ampoule of this can be mixed with water-based lubricant to make the jelly in an emergency gasoline or diesel fuel so prolonged contact may produce a chemical injury to the skin more effectively removed with soap solution than water alone then you have hot tar so burns these are thermal burns not chemical burns you want to immerse in cold water and once the tar is cooled there is no need to try and remove it in the field",
        "Inhalation Burns From Other Toxic Chemicals": "so inhalation burns from other toxic chemicals the solubility properties of the gas and where it affects the airway so high water soluble gases will react with mucus membranes of the upper airway slightly water soluble gases will react with tissue over time and moderately water soluble gases will depend on the concentration that is breathed in hydrofluoric acid so aggressively binds to the calcium ions and it may require the administration of iv calcium so it's often often results in death so have a high index of suspicion for irritant gas exposure if the patient was involved in a fire explosion or contaminated environmental situation irritant gas will usually cause burning of the eyes signs of upper airway swelling may signal an acute upper airway obstruction such as if you hear strider then signs of lower is wheezing and desaturation perhaps pulmonary edema raging ranging from crackles to of course pink froth so maintain the o2 monitor signs and can of the continued airway compromise an administered aerosolized beta agonist okay so",
        "Chemical Burns of the Eye": "chemical burns of the eye so chemicals known to cause burns to the eyes are the acids the alkaloids the dry chemicals and the phenols assessment and management so flush the eyes with copious amounts of water consider supporting the patient's head under the faucet or at an eye wash if the patient wears contact lenses pause after a minute or two to allow the patient to remove them irrigate well underneath the eyelids and patch the eyes with lightly applied dressings and begin to transport the morgan lens may make eye irrigation more comfortable and effective so so important to keep fluid running through the morgan lens during its insertion and removal suction can occur between the lens of the eye and the fluid flow is stopped before removal after flushing the ph of the eye can be tested with a ph paper and typically done at the hospital",
        "Electrical Burns and Associated Injuries": "okay so next we're going to talk about electrical burns and associated injuries so electrocution this causes an average of 400 deaths a year it causes 4 400 injuries each year it may result in two injuries so at one point you'll have where the electricity entered the body that's the entrance wound and one where you have the exit and that's the exit wound the degree of tissue injury related to is the resistance of the body tissues so wet then clean skin offers less resistance than dry thick dirty skin intensity of the current that passes through the victim the duration of the exposure in the direction of the flow the current in the body so as electrical currents travel into the body it is converted the heat which follows the current flow the greater the current flow the greater the generated heat so when the voltage is low the current follows a path of least resistance when the voltage is high the current takes the shortest path alternating current is more dangerous because it can cause repetitive muscle contractions the significance of the direction of the current flow so current moving from one hand to another is particularly dangerous because the current may then flow across the heart several types of electrical burn so there's true electrical injury it's the most common type of electrical burn it may be the bullseye lesion at the site and it may be centralized or charred zone of full thickness burns there's a middle zone of cold gray dry tissue and then the outer has a red zone of coagulation necrosis and then taser effects so there are devices such as a electrical weapon or taser incompatible people via electro muscular distribution so taser darts can be seen as small impaled objects with a fish hook like barb at the end then there's the arc type or flash burn this is a electro thermic thermal injury caused by an arcing of electrical current the arc has a temperature of about 3000 degrees celsius to about 20 000 degrees celsius it's high enough to produce significant charring and then there's a flame burn that occurs when electric electricity ignites a person's clothing or the surroundings there's a strong possibility of severe internal injury with these burns and burns may only be one of the problems that experienced by the patient who has come in contact with the electrical source two most common causes of death from an electrical injury are asphyxia and cardiac arrest so asphyxia occurs when the prolonged contact with alternating currents induces contractions of the respiratory muscle the current passes through the respiratory center and the brain and knocks out the impulse to breathe and then there's the cardiac arrest so the cardiac arrest may occur from hypoxia or as a direct result of the electrical shock currents as small as 0.1 amp can trigger ventricular fibrillation in the in the as they pass through the heart electricity can disrupt the nervous system also and complications include peripheral nerve deficit seizures delirium confusion or coma electrical contact may affect muscle coordination and strength it may cause cataracts in the eyes and severe muscle spasms may lead to fractures and dislocations when it comes to the assessment never let obvious injuries distract you from the complete assessment the first priority is to protect yourself in bystanders once the electrical hazard has been neutralized assess the patient start cpr and attach the monitor to identify v-fib open the airway using a jaw thrust maneuver cardiac monitoring is indicated for 24 hours after the injury make careful note of the patient's state of consciousness and record the vital signs try to determine the path of the current which has taken through the body a rigid abdomen or extremity may indicate a serious internal injury you want to prioritize the care and if the patient is in a life-threatening begin related care and prepared to transport immediately administer o2 early manage the patient for impending shock and make transport decisions early consider the regional resources and talk with the patients and explain what you're doing",
        "Lightning-Related Injuries": "when it comes to lightning related injuries lightning strikes with a massive discharge of electricity it occurs between two bodies that have different charges an example would be a strike between a thunder cloud and the ground if an object projects above the surface of the earth that is better conductor of electricity than the air the object will attract the lightning bolt a patient or a person need not sustained a direct hit from lightning to be injured in fact most victims are not struck directly the victim may be splashed by lightning striking a nearby tree or another projected object and ground current produced by lightning striking the ground can also cause severe injuries the best treatment for lightning injuries is prevention so don't be the tallest object that is a good conductor don't stand under a tree near the tallest object that's a good conductor take shelter in the most substantial structure that you can and avoid touching good conductors during a lightning storm including plumbing fixtures fences electrical appliances particularly those connected to wires outside lightning carries enormous electrical power its energy can reach 1 million volts peak currents can be in the range of 200 000 volts it is a direct current and duration of exposure in milliseconds lightning injuries tend to resemble blast injuries it damages the temperature membrane of the ears and air containing internal organs continued ventilatory support may be required if left untreated the patient who experiences respiratory rest after a lightning strike may become susceptible to the secondary cardiac arrest temporary paralysis of the legs and permanent paralysis and quadriplegia have been reported so there's two special considerations when you're doing your assessment if the lightning storm is still ongoing get any patients and rescuers to a safe place lightning can strike twice in the same place and there is no hazard in touching the victim afterwards a lightning strike is apt to injure more than one person so upon arrival the scene perform a rapid size up to determine the number of patients cpr when necessary so patients with cardiac arrest caused by lightning strikes deserve aggressive continuing cpr minimize the interruption in compressions and push hard and fast with full chest recoil management includes making sure the scene is safe priority given to patients who are not breathing performing cpr as needed administered supplemental oxygen consider an 8 18 gauge catheter and lactated ringers wide open to keep the kidneys flushed cover surface boring burns with dry sterile dressing splint fractures in a mobilized c-spine",
        "Radiation Burns": "radiation burn so suspicion of radiation exposure in ongoing exposure special response units may be needed with radiation detectors there are three types of ionizing radiation alpha beta and gamma so alpha particles have little penetrating energy energy and are easily stopped by the skin beta particles have greater penetrating injury and can travel much further in the air and gamma radiation is very penetrating and easily passes through the skin and solid materials units of radiation measure so you have radiation equivalent in man and that's rem radiation equivalent in man radiation absorption dose and that's rad rad the small amounts of everyday background radiation is measured in rad the amount released in a major instant may be measured in gv so there's mild radiation exposure moderate severe and fatality exposure radiation contamination so acute radiation syndrome causes hematologic nervous system and gi changes changes may occur over time and will not be apparent during contact with ems providers the amount of radiation and duration exposure will affect how rapidly signs and symptoms present and the onset of vomiting soon after exposure is a predictor of a poor outcome consider this fact when triaging okay so radiation contact burns a person who handles a radioactive source briefly may sustain a local tissue injury an injury can resemble anything from a superficial burn to a chemical burn burns appear hours and days after exposure we talk about assessment of the radiation burns determine if the scene's safe to enter first determine what protective gear you need it may be appropriate to contact the hazmat team once the scene is deemed safe proceed with your primary so you have to do of course the abcde and prior trace the patient's care when confronted with large numbers of patients who have been exposed to radiation and received burns keep the 30 rule in mind when triaging and consult the medical control in complicated cases decontaminate patients before you transport and gently irritate irrigate open wounds notify the emergency department as soon as possible and with contact with radio asian burns decontaminate the wound as if you're decontaminating a chemical burn antidotal therapy should be considered only with the guidance of knowledgeable physician or public health agency and limit your duration of exposure increase your distance and attempt to place shielding between you and the source of the radiation",
        "Management of Burns in Pediatric Patients": "all right so management of burns impedes patients so escaping from a fire can be difficult for children they are not as effectively awakened by smoke detectors and they are often disoriented after walking children have thin skin delicate respiratory structures and may eat may be more easily damaged by thermal insults then are those of older children or adults so in children fluid resuscitation may be more challenging they may require more fluid per kilogram than adults because of their increased body surface weight ratio and they may require dextrose containing solutions earlier than adults because of the poor stores blood glucose monitoring should be routinely performed in serious burn children all right so approximately 1300 older adults die of fire related causes each year burns from fires caused by smoking while wearing o2 and there's also cooking fires so elderly patients are particularly sensitive to respiratory injuries older patients require older patients may have poor glycogen stores as well and poor glucose levels should be checked to assess for hypoglycemia cardiac monitoring should be implemented in pulmonary edema is more likely to develop",
        "Long-Term Consequences of Burns": "when it comes to long-term consequences of burns so people with major illnesses average about one day of impairment treatment for each one percent of tbsa burned survivors are with long-term consequences including problems with thermoregulation motor function and sensory function caring for patients with severe burn injuries can be horrifying fire scenes are chaotic and dangerous patients are in severe pain and burn hair and flesh may be smelled sheets of tissue may be peeled off so with proper training confidence and courage you can make a large impact in the treatment of the survival of burn patients okay so this concludes chapter 32 burns lecture we hope that you've enjoyed it if you did go ahead and like our channel and subscribe so we're going to be producing all the chapters thank you"
    },
    {
        "Introduction": "hello and welcome to the paramedic lecture of chapter 31 soft tissue trauma so let's get started the skin is the largest organ of the human body it serves as the interface between the body and the outside world so injuries involving the skin are common a wound is an injury to the soft tissue with or without involvement of the subcutaneous tissue and muscle generally low priority injuries unless they compromise the airway or are associated with massive bleeding now always search systematically for other injuries or life-threatening conditions before treating soft tissue trauma do not let dramatic soft tissue injuries distract you from conducting a thorough primary assessment the body's soft tissues can be injured",
        "Incidence, Mortality, and Morbidity": "through a variety of mechanisms three so you have blood injury penetrating and burns and we're going to talk about that next so blunt injury that's when the energy exchange between the patient and the object is more than tissues can handle so for example when a person's head hits a steering wheel during an automobile crash then you have penetrating injury and that's when an object such as a bullet or a knife breaks through the skin into the body it could cause an entry wound and possibly an exit wound and then you have burns and they may cause soft tissue injuries as well so soft tissue trauma is the leading form of injury open wounds cause approximately 6.5 million emergency department visits wound care is one of the most frequently performed procedures in the emergency department across the united states most require basic interventions such as wound irrigation dressing bandaging and limited suturing but death from a soft tissue injury is extremely rare and typically related to hemorrhage or infection so uncontrolled bleeding can cause shock and death and in open wounds invading pathogens can cause local or systemic infections it can be limb or life-threatening especially in patients with pre-existing medical conditions so preventing soft tissue injuries involves simple protective actions you use gloves while you're working with abrasive materials use of safety devices on sheens and teaching children to avoid using sharp objects plastic scissors knives and drinking cups are designed to reduce risk of injury to children",
        "Anatomy and Physiology Review": "so let's talk about some anatomy and fizz review so skin is a complex organ with a crucial role in maintaining the consistency of the internal environment and that's also known as homeostasis it protects underlying tissue from injury including those by temperature extremes ultraviolet radiation mechanical forces chemicals and invading micro microorganisms it aids in temperature regulation and prevents heat loss when core body temperature starts to fall it causes heat loss when core temperature body rises it prevents excess water loss from the body and drying of the tissues it acts as a sense organ so you have sense receptors in the skin and they mediate changes in temperature touch body position and pain sensation and it responds to injuries and wounds with inflammation causes redness and increased warmth and painful swelling blood vessels dilate and allow fluids to leak into damaged tissues and it provides more nutrients and oxygen to these tissues which aid in healing when there is significant skin damage it may make the patient vulnerable to a bacterial invasion temperature instability or fluid balance disturbances",
        "Epidermis": "the skin is composed of two layers first you have the outer layer and that's the epidermis it's the first line of defense it consists of five layers the stratum corneum is the outermost layer of hardened non-living cells that shed then you have four inner layers of living cells that divide to give rise to the cells of the stratum corneum they contain a number of cells called melanocytes that contain melanin granules the skin's darkness is directly related to the amount of melanin present the cells of the stratum corneum are constantly shedding and replaced by new cells that move up through layers of the epidermis this figure shows the layers of the skin okay so the dermis is the inner layer it's a tough highly elastic layer of connected tissue its specialized structures in the dermis include nerve endings blood vessels sweat glands hair follicles and sebaceous glands",
        "Subcutaneous Tissues": "the subcutaneous tissue is the layer between the dermis and the underlying muscle and bone it isolates protects and stores energy in the form of fat deep fascia",
        "Deep Fascia": "is a thick dense layer of fibrous tissue below the subcutaneous tissue tendons muscles and bones are located below this layer",
        "Skin Tension Lines": "skin tension lines so let's talk about this skin is arranged over body structures in the way that creates tension so they vary by body region they occur in patterns known as tension lines static tension develops over areas with limited movement so for example the scalp lacerations occurring parallel to skin tension lines may remain closed larger wounds may be pulled open and require closure so even small lacerations laying perpendicular to tension lines result in wounds that remain open healing is slower in an open wound and scarring is more likely dynamic tension is found over muscle so tension varies according to muscle contraction and skin movement open injuries interfere with healing because they disrupt the clotting process and disrupt the tissue repair cycle an abnormal scar may prompt scar revision surgery so surgeons take skin tensions into account when choosing the revision procedure this should be considered when a wound debridement is necessary and impaled objects must be removed so next let's talk about open versus closed wounds and so closed wounds are soft tissue beneath the skin when it's damaged but the epidermis is not broken patients may have underlying trauma to organs and other structures under the skin characteristics closed wounds is a contusion or otherwise known as a bruise and the skin is intact but damage occurs beneath the epidermis if a small blood vessels are damaged echomosis and eccomosis is black and blue mark will cover the area if a large blood vessel is torn a hematoma now that's a collection of blood beneath the skin will appear as a lump with bluish discoloration open wounds now those are characterized by a disruption in the skin they include abrasions lacerations avulsions amputations bites impaled objects and blast injuries high pressure injection injuries and puncture wounds they're potentially more serious than closed wounds are vulnerable to infection and generally depends on how much the wound is managed greater potential for serious blood loss so a closed wound has a restricted area where the blood can go so it's limiting the amount of loss whereas an open wound can cause total blood volume loss and certain wounds should always be evaluated by a physician and here's a list of them on the table 31-1",
        "Crush Injuries": "crush injury so let's talk about those next crush syndrome occurs when um because of a prolonged compression force that impairs muscle metabolism and circulation it prevents flowing of extrication or release of the entrapped limb so external appearance may not present level of internal damage grotesque injuries may not be the primary problem always concentrate on life-threatening tissue before addressing injured extremities soft tissue injuries in the context are almost always less important than injuries occurring beneath the skin so this is covered in greater detail in chapter 37 orthopedic trauma",
        "Blast Injury": "so blast injuries there are explosions and they can result in many types of injuries including soft tissue trauma abdominal trauma skeletal trauma and a blast lungs and that's covered in detail in chapter 29 trauma systems and mechanisms of injuries um assess a blast scene for hazards before entering of course okay next",
        "The Process of Wound Healing": "we're going to talk about the process of wound healing and first homeostasis so the primary concern in wound healing is this incessation of bleeding so blood loss hinders provision of vital nutrients and oxygen to the injured area and impairs body's tissue ability to eliminate waste the end result is abnormal or absent functioning and it interferes with homeostasis vessels platelets and clotting cascade must work together to stop the bleeding soft tissue injury causes the release of chemicals that constricts the blood vessels this leaves less space for the blood to flow platelets are activated by this chemical release they adhere to the affected area and other platelets forming a platelet plug this temporarily stops blood loss as is the beginning of the blood clot formation next you have inflammation additional cells enter the damaged area to repair it white blood cells migrate to the injury to combat any pathogens that have entered and chemicals and proteins are released to signal repairing cells to the injury area you have granulocytes and microphages they engulf bacteria through phagocytosis it's ingestion of damaged cellular parts then you have lymphocytes those are a type of white blood cells they destroy bacteria and pathogens and mast cells release histamine in early inflammation stages this causes blood vessel dilation increases blood flow to the injured area and creates red warm area at the site it makes capillaries more permeable and may be swelling as fluid leaks from the capillaries then it leads to removal of foreign material damaged cellular parts and invading micro microorganisms okay next you have the a big word called epithelialization and this is a new layer of epithelial cells it's moved into the outer layer of the skin to replace what has been lost in the injury so except for clean incisions a reconstructed area seldom regains its previous look you have neovascularization and that's when new blood vessels form as the body attempts to bring oxygen and nutrients to the injured tissues new capillaries form from intact capillaries adjacent to the damaged skin and because they are new and delicate bleeding may result even from a minor injury and it may take weeks to months for new capillaries to be as stable as previous ones so next you have the the collagen synthesis and so collagen is a tough fibrous protein in scar tissue hair bones and connective tissues the repair unit is synthesized by fibroblasts provides stability to damage tissue and joins wound barriers to close open tissues cannot restore damaged tissues to form or strength however",
        "Alterations of Wound Healing": "so alterations of wound healing wound healing does not follow a pattern described because there may be infection or abnormal scarring excessive bleeding or slow healing so some medications delay healing such as corticosteroids or nsaids you also have anticoagulants that can slow the healing medical conditions may interfere with healing as well so advanced age alcoholism uremia diabetes hypoxia anemia of course peripheral vascular disease malnutrition or cancer or hepatic failure so there are also anatomic factors that affect wound healing and it could be areas of repeated motion such as the fingers they heal heal slower splinting to prevent this movement helps and the positioning of an open wound related to skin tension lines affects wound healing and scarring as well high risk wounds include human and animal bites carry a high risk further infection the mouth is a good environment for bacteria to grow microorganisms may be embedded in injuries from foreign body or organic matter a foreign body in place on evaluation should be left there removal of the object could allow for more bleeding and do not remove an impaled object in the field unless it interferes with the patient's airway other high-risk wounds include injection wounds with significant uh devaletized tissue crush wounds or wounds in immunocompromised patients or injuries to patients with poor peripheral circulation next we're going to talk about abnormal scar formation so excessive collage information can occur if the buildup and breakdown phases of healing are not in balance this can lead to hypertrophic scars and they occur in high tissue stress areas such as the elbows or knees and scars do not extend past wound margin borders and uh they tend to form in people with light pigmented skin and then you have keloid scars they tend to develop in people with dark pigmented skin they grow over wound margins and can become larger than the wound area they tend to form in the ears upper extremities lower abdomen and sternum pressure injuries and in the field you'll hear these called pressure ulcers they occur when the patient's bedridden pressure is applied for prolonged period in an unresponsive or immobilized patient involved tissues are deprived of oxygen and this leads to localized hypoxia and cell deterioration so prevention include determining risk and providing a mechanism to reduce or release pressure on the skin so wounds requiring closure some wounds require closure with sutures staples or glue for optimal healing and wounds that may need closure include open injuries that affect cosmetic areas such as the lips face or eyebrows gaping wounds and wounds over tension lines dick loving injuries need irrigation and debriefment and ring injuries and skin tears open injuries generally should be closed within 24 hours initial hospital management involves assessment for foreign material then irrigation before deciding an appropriate closing option there are three types of wound closures you have the primary closure and that's when wound margins are brought together as primary treatment secondary intention that's dressing high risk wounds to allow them to heal from the inside out and then you have delayed primary closure that's a delayed closure of the wound initially undergoing secondary intention patients with sutures need follow-up care to determine if healing is progressing normally sutures may need to be removed to allow draining of infectious material so let's talk about infection next any break in the skin surface can lead to infection larger and deeper penetrations carry higher risk for infection there is a longer healing time and it may be additional complications or a systemic infection may occur pathogens grow and multiply once they reach body tissues so clinical signs of an infection may not appear for several days visible signs include pus warmth edema local discomforts or red streaks adjacent to the wounds and this indicates inflammation of the lymph channels more serious infections can cause systemic changes such as fever shaking chills joint pain or hypotension",
        "Patient Assessment": "all right so now we're in the patient assessment area and we're gonna start with so skin trauma once again it's rarely immediately life-threatening stay focused on assessment process to identify threats to you and your crew and to identify threats to the patient",
        "Scene Size-Up": "and as always we're going to start with the scene size up and the safety address that first after the scene is deemed safe evaluate mechanism of injury if a significant moi keep a high index of suspicion even if external injuries appear minor consider the force involved to determine likelihood of internal damage and skin injuries often include exposure to blood and body fluids so protect yourself and your patient",
        "General Impression": "then we move into the primary survey so form your general impression and determine any life threats of course altered level of conscious lack of airway inadequate breathing uncontrolled bleeding or a significant moi may be the life threat you should address and then your abcs determine if the patient is alert responsive responsive to pain or completely unresponsive and assess airway immediately so immediately correct anything that interferes with the airway and assess the patient's breathing so determine whether breathing is abnormally slow rapid or excessively deep or shallow and then assess the c so the circulation so palpate the pulse and check the skin signs if no pulse is present of course take resuscitative measures pale or ash and skin points to indicate perfusion cool moist skin is an early indicator of shock and ensure patient is adequately exposed during your primary assessment so preserve the clothing as evidence and cut around rather than through knife or bullet holes and control severe hemorrhaging with a tourniquet it takes precedence over everything else of course that's a life threat",
        "Transport Decision": "and then d that's your transport decision so transport patients with significant trauma and patients with isolated injuries can often be treated on scene so obtain a set of baseline vital signs and your sample history",
        "History Taking": "ask the patient family members or bystanders about the events leading to the injury ask them was the patient wearing a safety belt or how fast was he driving how high was the fall or did the patient lose consciousness what type of weapon was used ask about a tetanus booster if there's time in the patient's conditional housing record info on the patient care report and ask about prescribed over-the-counter medicines especially if they interfere with homeostasis okay so warfin or an anticoagulant is a high priority for a complete medical history use the mnemonic sample",
        "Secondary Assessment": "right so the secondary assessment it's a more thorough exam and it should be conducted in route if there's a significant moi adequate time or if a patient is stable examine every anatomic region for hidden injuries and clinical signs and do not delay transport if the patient is in critical condition",
        "Reassessment": "reassess frequently and that should be made in route to the hospital and vital signs should be obtained and evaluated and intervention should be checked complete and written document for every patient contact it includes relevant findings patient findings and describe patient presentation and body position on your arrival so specific injuries describing wounds in terms of size location depth and associated complications and record any interventions performed documenting how the patient responds to therapy or the patient's level of understanding of each intervention",
        "Emergency Medical Care": "okay so the emergency medical care aspect some basic management principles apply to nearly all scenarios and attend to both clinical issues and patients feelings",
        "Treatment of Closed Wounds": "treatment of closed wounds if an extensive closed injury is present bleeding may be significant swelling may compromise vital structures minimize bleeding and swelling by following the rice's mnemonic so help the patient rest that's the r by keeping him or her as quiet and comfortable as possible apply ice or cold packs to stimulate constriction of blood vessels apply firm compression to decrease bleeding usually manual at first or with an air splint thereafter elevate the injured part higher than the heart to encourage drainage and decrease swelling and apply split to prevent motion and decrease bleeding now air splints prevent motion and adds compression but they will not control arterial bleeding number three is swelling so due to blood from developing hematomas and the result is a fluid usually ice is early as possible so 20 on and 20 minutes off may help decrease swelling and speed up healing time",
        "Treatment of Open Wounds": "when we talk about the treatment of open wounds there are two general principles for treating them so control bleeding is the most effective method and then keep the wound as clean as possible",
        "Bandaging and Dressing Wounds": "so cover the wound provides an artificial barrier against microorganisms to help prevent infection control the bleeding it will stop all but the most serious bleeding and then limit the movement of it this helps the body recover from the injury variety of materials used for closing dressings and bandages so a dressing covers directly the wound and controls the bleeding and a bandage helps keep that dressing in place so both keep pathogens from entering an open injury",
        "Complications of Improperly Applied Dressings": "complications of improperly implied dressing so improper dressing and bandage application can cause significant complications when dressing and bandaging a wound always use a sterile as sterile of a technique as possible to avoid contamination irrigate open wounds with normal saline and if possible apply an antibiotic ointment to smaller open wounds do not use ointments on larger wounds these should be dressed once the wound is irrigated and clean blood around dressing sites before wrapping a bandage over the dressing so hemodynamic complications may include contr continued bleeding removing and in place dressing may risk clot formation disruption so if a wound continues to bleed just apply additional dressings in conjunction with the other interventions consider the use of a tourniquet if the extremity wound continues to bleed and perform frequent assessment to prevent unchecked blood loss exsinguination is the possibility if the pressure dressing does not stop blood loss and tourniquet is applied improperly structural elements can be damaged if the dressings are too tight so assess and re-just dressings and bandages if necessary when extremity dressings are in place assess distal pulses motor function and sensation",
        "Control of External Bleeding": "control of external bleeding so bleeding can be characterized by the type of blood vessel that's damaged you have capillary bleeding and that's a slow even flow of bright or dark red blood venous bleeding and that's likely to be slow and steadier with darker colored blood and then you have arterial bleeding this occurs in spurts with bright red blood most large open wounds have a combination of both arterial and venous and bleeding figure shows an example of arterial bleeding so direct pressure apply pressure over the bleeding wound to stop the blood from flowing into damaged vessels this allows platelets to form blood clots to seal the vascular walls if possible use dry sterile dressing to apply the pressure and steps for controlled bleeding are shown in chapter 30 bleeding splints so splints uh the movement of an extremity promotes blood flow and in an injured extremity motion may disrupt the clotting process and tear more blood vessels so attempt to limit movement of the injured extremity and then there's tourniquets so we especially use these if the extremity injury below the axilla or groin is severely bleeding other bleeding control methods are ineffective so some tourniquets can be applied with one arm and if a tourniquet is required follow the guidelines shown in chapter 30 bleeding hemostatic agents they can be used with direct pressure when direct pressure alone is ineffective they can be used with massive chest wounds or when a tourniquet placement is impossible dressings are impregnated with these agents and they're designed to facilitate the coagulation process they assist in clot formation so remove all other dressings before you apply a hemostatic dressing and also consult your local protocols",
        "Managing Wound Healing and Infection": "when you're talking about wound healing and infection there are basic measures which should be used in the pre-hospital setting for management of alternative wound healing wounds that look infected and are not healing properly should be dressed and bandaged and pain management may be indicated in severe instances",
        "Scalp Dressing": "scalp dressing so scalp injuries tend to bleed profusely direct pressure is usually affected effective in stopping the bleeding but determine the extent of the injury so significant trauma can cause skull damage such as a fracture balance bleeding control against the needs of possibly causing further damage to the skull so if the skull has been damaged apply pressure to the areas around the break a bulky dressing may help control the bleeding and prevent excessive direct pressure to the damaged skull pay attention to the skull shape when applying a dressing improperly applied dressings can slide up and down the scalp and hair may interfere in securing the dressings",
        "Facial Dressing": "facial injuries can cause significant anxiety you reassess the patient while taking care of the clinical needs direct pressure is affected to effective to control bleeding and if a false tissue is present attempt to place it as close to the previous position as possible bleeding tends to be heavy and assess for airway compromise be compared be prepared to suction and position the patient to allow for drainage check for life threats before managing dramatic looking facial injuries",
        "Ear or Mastoid Dressing": "ear or mastoid dressing so injuries are usually external do not place any dressings in the ear canal use god's gauze sponges to aid in stopping blood loss and do not try to directly stop blood flow from the ear canal cerebral spinal fluid may be leaking and halting blood flow may increase skull pressure so place a bulky dressing over the external ear and transport rapidly",
        "Neck Dressings": "when it comes to neck dressings anatomic structures in the neck include the large vessels airway and cervical spine so minor injuries can become major minor neck lacerations can lead to air embolisms and a small puncture can penetrate the spinal canal and an anterior anterior open wound dressing can disrupt the airway use occlusive dressing to prevent air from reaching the circulatory system and make sure dressings do not interfere with blood flow or movement of air through the trachea",
        "Shoulder Dressings": "shoulder dressing so they're relatively easy to dress and bandage and apply direct pressure to control that external hemorrhage and use a sling and swath to prevent shoulder girdle movement if immobilization is indicated",
        "Truncal Dressings": "and moving down into the trunk area assess for underlying trauma to the trunk or torso injuries cover open wounds with occlusive dressing taping only three sides assess breathing sounds in the chest wound situations to check for pneumothoraxes or hemothorax and continuously reassess the patient remember to use medical tape to secure the dressing and that wrapping the torso may interfere with breathing",
        "Groin and Hip Dressings": "okay groin and hip dressings manage with dressings and bandage application combined with direct pressure to control blood loss and when feasible genitalia injuries should be managed by the provider of the same gender of the patient remain professional and protect the patient's privacy and if the patient is reelected to allow a provider to dress a wound in the genital area provide the patient with the dressing and allow self-directed care if necessary",
        "Hand, Wrist, and Finger Dressings": "okay so hand risk and finger dressings these are among the easiest to properly dress and bandage dressing is applied over the wound and bandage material is wrapped completely around the area place the hand in the position of function whenever possible and the position of function is when you place a roll of gauze in the hand before dressing and bandaging the hand and wrist can be splinted if limited motion is necessary and leave the fingers exposed if possible for circulation access",
        "Elbow and Knee Dressings": "elbow and knee dressings not difficult to dress but movement can cause dressings to shift from the original position so if larger wounds are present immobilize the joint it's a good idea skin tension lines and high tissue stress can make even small wounds difficult to manage so important to assess distal neurovascular status and elbow injuries have a higher risk for neurovascular compromise",
        "Ankle and Foot Dressings": "ankle and foot dressings simple to dress and bandage as well control bleeding with direct pressure and always assess of course for distal neurovascular function before and after caring for the wound",
        "Pain Control": "okay pain control a cold compress may help reduce pain and diminish blood flow to the open wound apply a dressing and do not place the cold compress directly on the injury it um you want to avoid further damage morphine and other pain meds also as allowed by protocol might be necessary but carefully assess for allergies and document any information",
        "Abrasions": "okay so the pathophysiology assessment and management of these specific injuries and first we're going to talk about the abrasions so abrasion is a superficial wound that occurs when part of the epidermis is lost from or have been rubbed or scraped over a rough surface assessment and management so they typically ooh small amounts of blood they could be painful an infection is a danger because of possible contamination with dirt and debris do not clean an abrasion in the field and rubbing and brushing or washing can cause additional bleeding and unnecessary pain so cover the womb lightly with sterile dressing",
        "Lacerations": "and then you have a laceration so a cut inflicted by a sharp instrument that produces a clean or jagged incision so a laceration is a jagged or irregular cut and an incision is a clean linear cut incisions tend to heal better than lacerations can injure structures beneath the scent skin including tendons or ligaments or organs in body cavities and also bones when it comes to assessment and management the seriousness depends on the depth and the structures damaged may be source of significant bleeding especially in regions containing major arteries so your first priority of course is the bleeding control initially by applying direct pressure of the wound and a laceration of a major artery it can be fatal",
        "Puncture Wounds": "okay then puncture wounds caused by a stab from a pointed object such as a knife or nail can result in injury to underlying tissues and organs and depth cannot always be determined in the field so seemly superficial wounds may involve vital organs always suspect internal injury and shock with a puncture wound so consider potential depth of the wound speed and type of object involved relate to the potential depth and wound severity location is a factor the closest nest to important internal organs so usually not significant external bleeding but it may have extensive internal so unseen damage to other structures and systems treatment is similar to that of other open wounds look for an entrance and an exit take steps to prevent infection and if the patient refuses care inform them of the potential infection of the wound if it's not managed air may be injected under the skin and certain with certain puncture wounds so guns at close range or air pressure devices so monitor for edema and treat swelling with ice impaled foreign objects are a special type of puncture wound if the object is embedded in the wound immobilize the object and transport the patient so basic management for impaled objects do not remove the impelled objects because it may control uh may cause uncontrollable bleeding and use direct compression but do not uh not on the impelled object or immediately adjacent tissues do not try and shorten the object unless it's too cumbersome and stabilize the object with bulky dressing and immobilize the extremity so pre-hospital care is to limit movement as soon as possible to minimize the damage so for thin objects use gauze pads cut midway through the center vertically stack several pads arranging cut proportions so that the stacks overlap once the object is stabilized tape or bandage them securely secure larger objects with rolled towels or splinting material and secure the object as best as possible to create to create be creative if necessary and provide reassurance constantly assessing for risks to life rarely removal of an impaled object may be necessary if the object directly interferes with the airway and the patient is deteriorating or if the object interferes with chest compressions when the patient is in cardiac arrest or if the patient is impaled on an immovable object establish contact with medical control and ask for guidance",
        "Avulsions": "next we're going to talk about avulsions and avulsions are they occur when the flap of skin is partially or completely torn loose the amount of bleeding is dependent on the depth of the injury and it's also dependent of on the location of the injury principal danger is loss of blood supply to the evol skin flap and if the flap is still connected to the body or if it's kinked or folded back circulation will be compromised so skin will die unless circulation is restored quickly if wound is contaminated provide irrigation with sterile saline and you may see oozing from the wound and you may also see drainage okay so quickly irrigate the dirt and debris from the wound then gently fold the align flap back to the close to close to the normal position as possible cover with dry sterile compressed dressing and never remove the skin flap regardless of the sk of the size a surgeon may be able to reattach it ice packs on the surrounding area may decrease pain and swelling and increase the length of time the underlying tissue remains viable so if a patient is unstable do not delay transport for these wounds manage them in route",
        "Amputations": "okay so an amputation that's an avulsion involving the complete loss of the body part usually one or more of the extremities so hemorrhage can be severe and life-threatening and fractures may also be present and if a partial amputation is present soft tissue remains intact assessment and management so wound edges are usually jagged sharp bone edges may protrude and be aware of sharp bone protrusions during wound care cover the site with a large thick dressing and if the body part is completely amputated try to preserve it in optimal conditions for maximum chances of attachment once the patient has been stabilized so rinse off any debris using cool sterile saline and wrap it loosely in moist and gauze seal it in a plastic bag and place it in a cool container but do not allow it to freeze never warm it never place it in water and never place it directly on ice never use dry ice to cool it transport the patient in the amputated part as soon as possible if the amputated part is a limb or part of one notify the emergency department staff of the type of amputation and the estimated arrival time choose whether to transport to the nearest re-implantation center is the best option and if air medical control is needed",
        "Bite Wounds": "okay so now we're going to talk about bite wounds animal and human bites can cause soft tissue injuries most people bitten by animals do not report them but such bites can be serious so cat and dog mouths are contaminated with bacteria cat bites can pass along a gram negative bacterium that causes epiglottitis or endarcarditis and brain abscesses all such bites should be considered as contaminated and possibly infected and may require antibiotics a tetanus booster and suturing and dog bites may also be mangled complex wounds needing surgical repair human bites usually occur in the hand and human mouths contain a wide variety of pathogens as well any human bite that penetrates the skin should be considered a serious injury infection can occur if there is a delay in treatment and any laceration from a human tooth can cause a spreading infection for an animal bite place a dry sterile dressing and transport promptly if gross contamination irrigation with sterile water before placing a dressing should be considered and splint the arm or leg if it's injured determine and document when the bite occurred the type of animal and note if the wound is a human bite and what led to the biting incident rabies is a major concern with dog bites an acute fatal infection of the central nervous system it's extremely rare today thanks to pet inoculation and once signs appear in the human it's almost always fatal a particular concern are stray dogs and other wild mammals the very their virus sorry is a in the saliva of an infected animal and is spread by bites and licking of an open wound infection can be prevented by a series of vaccine vaccine injections limited soon after the bite and animals with rabies may not always show signs and symptoms so children may be seriously injured or killed by dogs and do not enter the scene until the dog is secured emergency treatment for animal bites so control the bleeding and apply a dry sterile dressing immobilize the area with splints advantage and provide transport for surgical cleaning and antibiotic antibiotic therapy most jurisdictions require that all animal bites be reported to our authorities such as the emergency department physician",
        "High-Pressure Injection Injuries": "high pressure injection injuries so they occur when a foreign material is forced injected into soft tissue often from a tool or machine failure in which a highly compressed air or liquid is suddenly released so some examples of these are hydraulic tools used to extricate patients from entrapment a force as small as 100 psi can break the skin and 5000 psi can penetrate both clotting or clothing and skin injury results from injection materials under great pressure entering the body causing an acute and chronic inflammation and damage from direct insult or the chemical inflammation ischemia from the compressed blood vessels or a secondary inflammation infection infections most severe when fuel or pain is injected when it comes to assessment and management it's very similar to the other types of injuries so you do the primary assessment address life threats determine the severity and specific consideration so you want to question the patient about the nature of the injury the type of the equipment and pressure used and the type of the fluid you need to pass all this information to the receiving emergency department physician so inspect the injury for the extent of the visible damaged skin palpate affected injury for signs of edema and compare it to the unaffected side and subcutaneous emphysema may be present so check for crepitus at injury site and the hand is most commonly injured site so assess for cap refill the ability to move the figure fingers and distal sensations treatment is limited in the pre-hospital setting you could gently irrigate the open wounds with normal saline and dress and bandage the open injuries so manage pain if necessary an injury may require emergent surgery to prevent amputation as well",
        "Facial and Neck Injuries": "okay so facial and neck injuries injuries may involve airway in a large blood vessels and suctioning and patient positioning may be necessary for airway patency open injuries to the jugular or carotid vessels may cause exsanguinations and physiological impacts of facial damage may occur assess and manage the immediate airway patency you want to immediately assess protection and oxygen flow is necessary and suction secretions deliver high flow oxygen with a non-re-breathing mask or bvm if ventilations are compromised consider using an advanced airway and if neither ventilation nor inhibition is possible a surgical airway is indicated bleeding control can be started while airway control is underway so if any ems provider is available address bleeding after airway is secured open wounds to the neck need occlusive dressings to prevent air emboli realign evolus skin a long neck and face to the original position if possible",
        "Thoracic Injuries": "so thoracic areas may have underlying chest trauma assess for management for there's four steps so inspection palpation auscultation and percussion examine the entire chest for visible injury listen for breath sounds in at least two sides on each side of the patient if diminished or absent on one side suspect a pneumo palpate the entire chest wall no any abnormalities and subcutaneous emphysema is indicative of tracheobronchial tree disruption so open wounds require occlusive dressings to prevent air and stop the progression of the pneumo in tape dressing of course on only three sides to layer to allow for the air escape",
        "Abdominal Injuries": "abdominal injuries range from minor to as evisceration so inspect the abdomen for injury signs palpate to identify pain or rigidity or distension and as the diaphragm travels downward during inspiration the relative size of the thoracic and abdominal cavities changed increased risk of drawing air up into the pleural space if the wound an open wound is present okay so soft tissue injuries in the abdominal area may not generally be primarily concerning but focus on the injury to the underlying organs could lead to a serious complication so specific care of abdominal organ injuries is covered in 36 chapter 36 abdominal and genital urinary trauma myositis is the inflammation of muscle it can be caused by an injury infection or overuse of the muscle and assessment and management so treatment is based on the patient's complaint and history you want to look for signs of infection such as a fever or muscle weakness fatigue on exertion treatment is based on the patient's presentation and patient transport to the hospital for definitive diagnosis okay so grain green is dead tissue blood supply delivery to the tissue is interrupted or has stopped and it could be caused by injuries infections long-term tobacco use poor peripheral circulations or burns frostbite and also wounds so there's a toxic producing bacteria that leads to development of gangrene it causes production of a foul smelling gas wet gangrene causes sepsis and the patient can die within hours dry gangrene can take up to months to develop so suspect gangrene if the patient has chronic risk factors such as diabetes if there's numbness coolness or swelling of the extremity or discoloration of the limb to black blue or red if untreated the skin will become necrotic infection will lead to sepsis so prompt recognition and early aggressive hospital therapy is necessary so tetanus is caused by an infection of an anaerobic bacterium it's caused it causes the body to produce a potent toxin which results in painful muscle contractions strong enough to fracture bones it's rare because of a vaccine availability but part of and it's part of a regular childhood immunizations in the united states and a booster every 10 years is needed so assessment and management so muscle stiffness may be noted first in the jaw and that's called lockjaw and then the neck with progression down the remainder of the body so early recognition is important then there's necrotizing fasciitis and that is inflammation of the fascia necrotizing of course involves tissue death from the bacterium infection it's caused by more than one infecting organism mostly commonly group a streptococcus so assessment and management recognition of an ems personnel is difficult and but early intervention is crucial so look for a history of vector transmission such as insect bites or jellyfish things and skin may be red and warm it may also have a fever night sweats chills or vomiting and diarrhea and take standard precautions and transmit the patient to the hospital for diagnosis antibiotic therapy and surgical debridement are among the available treatments perinecia it's the most common infection of the hand in the united states a bacterial infection located near the nail plate if not recognized and treated it can spread through the hand and into the circulatory and lymphatic system so assessment and management will cause a small pustule or redness with or without pus and there may be an abscess at the site so transport the patient for out of auto antibiotic therapy or lancing of the abscess okay so this concludes the lecture for chapter 31 soft tissue trauma and thank you for joining us today"
    },
    {
        "National EMS Education Standard Competencies": "hello and welcome to the emergency care in the streets chapter 30 bleeding lecture after managing the airway recognizing bleeding and understanding how it affects the body are perhaps the most important skills you can learn as a paramedic this chapter begins with a review of the anatomy and physiology of the cardiovascular and respiratory systems and their roles in keeping blood flowing between the lungs and peripheral tissues control of external hemorrhaging including the use of tourniquets and the role of hemostatic agents are discussed hemorrhagic shock or shock resulting from bleeding both internal and external is also discussed",
        "Introduction": "okay so let's begin a before b except after c the paragram has shifted from focusing on first airway to focusing on circulation when severe hemorrhaging is present or suspected bleeding is an extremely time sensitive condition and the goal in trauma care is to maintain perfusion given massive hemorrhage c of circulation takes priority over a and b airway management is not successful if there is inadequate circulation to transport the oxygen to perfuse the tissues even seemingly inconsequential bleeding may be dangerous it may initially cause symptoms as vague as general weakness but progress to shock understanding bleeding management requires understanding the anatomy and physiology of the cardiovascular and respiratory systems",
        "Anatomy and Physiology": "so let's talk about these systems the cardiovascular system keeps blood flowing between the lungs and peripheral tissues the right side of the heart pumps blood to the lungs and the left side of the heart receives blood from the lungs and pumps it around the body the circulatory system must function well to deliver oxygen to body tissues in the lungs blood unloads gases waste products and picks up oxygen the process is reversed in peripheral tissues blood unloads oxygen and picks up waste if blood flow were to stop or slow cells in the brain heart and other organs would not be able to eliminate waste and would be engulfed by toxic byproducts oxygen delivery to tissues would be disrupted and cells could switch to an emergency metabolic system for a few minutes anaerobic metabolism produces more acids and toxic waste and cells would begin to die within a few minutes of circulatory failure to survive the body compensates to maintain systolic blood pressure and to perfuse to the brain and heart at the expense of other areas okay so the circulatory system requires three intact components to keep blood moving through the body first the pump and that's the heart and the pump in the blood vessels the pipe and the blood vessels and the fluid which is the adequate fluid volume",
        "The Cardiac Cycle": "so let's talk about the cardiac cycle and it's a repetitive pumping process that begins with the onset of cardiac muscle contraction and ends with the next contraction contraction results in pressure changes in the chambers and blood moves from high pressure to low pressure preload is the amount of blood returned to the heart to be pumped out and afterload is the pressure in the aorta or the peripheral vascular resistance against which the left ventricle must pump blood the higher the afterload the harder for the ventricles to eject the blood higher after load reduces stroke volume and that's the amount of blood ejected per contraction so let's talk about the blood pressure and the cardiac cycle is connected to bleeding and shock through its relationship to blood pressure so blood pressure level is the dividing line between the stages of shock blood pressure equals cardiac output times peripheral vascular resistance so peripheral vascular resistance is measured as a mean arterial pressure or map map is the diastolic pressure plus one-third the pulse pressure the pulse pressure is calculated by subtracting diastolic blood pressure from the systolic blood pressure so map equals diastolic blood pressure plus one-third systolic blood pressure minus diastolic blood pressure cardiac output is the amount of blood pumped through the circulatory system in one minute it's expressed in liters per minute or l slash min and uh the cardiac output or co equals stroke volume times pulse rate what influences stroke volume pulse rate or both also affects the cardiac output so increased venous returns stretches ventricles and results in increased cardiac contractility frank starlin's mechanism or starling's law of the heart is if the muscle is stretched slightly over before stimulated to contract it contracts with greater force a normal heart continues the pump the same percentage of blood returned to the right atrium if the more blood returns the heart pumps harder more blood is pumped with each contraction but the ejection fraction remains unchanged this maintains normal cardiac function through the position changes such as coughing or etc connecting and expanding the two equation yields this equation so blood pressure equals stroke volume times heart rate times the um pvr and that's also known as map this formula explains shock and indicates where treatment needs to focus",
        "Blood and Its Components": "so let's talk about the blood and its components so the blood is um it consists of plasma or for and formed elements and cells suspended in the plasma so those form elements include the red blood cells and that's about 45 of the blood volume the white blood cells and that's less than one percent in the platelets that's also less than one percent the purpose of the blood is to carry oxygen and nutrients to its tissues to carry cellular waste products away from the tissues and numerous other functions of the formed elements including fighting infection and controlling bleeding plasma is watery straw colored fluid more than half of the total blood volume 92 water and 8 percent dissolved substances and then there's platelets which are small cells essential for clot formation coagulation process is a complex series of events involving clotting and other proteins in calcium",
        "Blood Circulation and Perfusion": "so arteries carry blood away from the heart while veins transport blood back and arteries get smaller the further away from the heart that they are they branch into arterioles and then divide e into even smaller capillaries oxygen and nutrients pass out of the capillaries into cells and carbon dioxide and waste products enter capillaries through diffusion capillaries gradually enlarge to form venules and venules merge together to form larger veins which empty blood into the heart perfusion is the circulation of blood within the organ or tissue and amounts of adequate amounts to meet the cell's current needs blood must pass through fast enough to maintain adequate circulation and slow enough so cells can exchange oxygen and nutrients for waste some tissues such as lung and kidneys require a constant blood supply most tissues only require an intermittent blood supply muscle needs minimal blood supply during sleep but a large blood supply during exercise and the gi tract requires blood flow after eating but only a small fraction at other times so the autonomic nervous system adjusts blood flows to the to the body's needs it's divided into the sympathetic and parasympathetic component that keep vital functions in balance the sympathetic system the fight or flight or freeze mode that's the body's reaction to internal and external stress the actions include faster and stronger heart contractions faster and deeper respirations along with bronchodilation shunting of blood to vital organs and slowing or since cessation of digestive functions and the parasympathetic nervous system is the rest and digest mode the body rests and repairs itself actions include slowing the heart rate slowing the breathing rate and an increase in digestive functions the vasomotor center in the medulla oblongata helps regulate blood pressure if a drop in blood pressure is detected baroreceptors send stimuli to brain via cranial nerves nine and ten this causes an increase in the sympathetic stimulation and if blood pressure rises the opposite is true the endocrine system also responsible of pressure changes a fallen blood pressure causes the release of aldosterone from the adrenal glands and an antidiuretic hormone from the pituitary gland these releases cause additional peripheral vasoconstriction and conservation of water in the kidneys if the cardiovascular system falls tupa fails to provide significant circulation for the body the result is hypoperfusion or shock delivery of oxygen to keep the body's tissue from becoming ischemic depends on adequate heart rate stroke volume hemoglobin levels or arterial oxygen saturation",
        "Pathophysiology of Hemorrhage": "so let's talk about hemorrhage and hemorrhage means bleeding an external visible hemorrhage can easily be controlled by direct pressure or pressure bandages but internal hemorrhaging is usually not controlled until a surgeon can locate the source they must rely on signs and symptoms to determine the extent and severity so let's first talk about external hemorrhaging and the extent or severity is often a function of the type of wound and types of injured blood vessels and so the capillary that usually it's a oozes and the vein usually flows in an artery blood usually spurts if the laceration or tear is large enough the person can usually exsanguinate in as little as a few minutes these descriptions are not infallible and different vessels may bleed differently due to circumstances some injuries may have more or less external hemorrhage than expected okay so an example would be an amputation with little bleeding because the wound was cauterized by heat or severely crushed legs with hemorrhage that can only be stopped by the use of tourniquets next we're going to talk about internal hemorrhage so as a result of trauma hemorrhage may appear in only an area of a body a long bone fracture will produce a relatively small amount of bleeding and bleeding in the trunk tends to be more severe and uncontrolled so non-traumatic internal hemorrhage usually occurs in cases of gi bleeding or ruptured atopic pregnancy or maybe ruptured aneurysms internal hemorrhage must be treated promptly signs do not always develop quickly so other signs and symptoms and mechanisms of injury are needed to make a diagnosis pay close attention to complaints of pain and tenderness and development of tachycardia and polar be alert to development of shock",
        "The Significance of Hemorrhage": "okay so we're going to talk about the significance of hemorrhage next adult males contain approximately seven mls of blood per kilogram of body weight in females it's 65 milliliters per kilogram the body cannot tolerate an acute loss of more than 20 percent if the typical adult loses more than one liter of blood vital signs will change sufficiently increasing the heart rate and respiratory rates and decreasing the blood pressure infants and children may have the same effect with similar amounts of blood loss for example one year old has a total blood volume of two pints and that's 950 milliliters so sufficient symptoms may appear after only three to six ounces and that's 100 to 200 milliliters of blood loss compensation depends on how rapid a person bleeds consider bleeding to be serious if any of the following are present so a significant mechanism of injury especially if it suggests severe force to the abdomen poor general appearance of the patient signs and symptoms of shock significant amount of blood loss or rapid blood loss or uncontrollable bleeding",
        "Physiologic Response to Hemorrhage": "physiologic response to hemorrhage so bleeding from an open artery is bright red it spurts in time with the pulse it's difficult to control and as the amount of blood is in circulation drops the spurting diminishes blood from open veins is darker it flows more steady and it's easier to manage and bleeding from damaged capillary vessels is dark red and it oozes steadily but slowly venus and capillary bleeding is more likely to cut spontaneously than arterial bleeding and bleeding tends to stop within about 10 minutes on its own the open ends of the vessel begin to narrow and that's called vasoconstricting reducing the amount of bleeding and platelets aggregate at the site and plug the hole sealing the injured areas homeostasis proceeds through three steps vasoconstriction platelet aggregation and fibrogen weaving into the clot and forming fibrin to hold the claw clot together and it's con this controls bleeding bleeding will not stop if the clot does not form unless the injured vessel is cut off from the blood supply okay so the system may fail in certain situations and some medications including anticoagulants and blood thinners interfere with clotting beta blockers may prevent vasoconstriction and in some injuries the damage may be too extensive for the clot to block the hole only part of the vessel may be cut preventing constriction cold will inhibit enzymes involved in clotting process as well and all bleeding patients should be kept warm hemophilia is a condition where one or more the blood clotting factors are missing so several forms of the illness most are hereditary and some are more severe all injuries no matter how trivial are potentially serious and patients should be transported immediately okay so let's talk about the trauma triad of death next and this is a combination of hypothermia coagulopathy and acidosis that significantly increases mortality in trauma patients conditions create a positive feedback loop and they intensify one another rapidly worse of worsening the patient's condition so coagulopathy is a disruption of the body's ability to clot and it can lead to farther hemorrhage leading to increasing hypoperfusion this hyperperfusion causes the cells to use anaerobic metabolism releasing additional acidotic compounds into the blood this acidosis reduces myocardial performance further reducing oxygen delivery and body's metabolism leading to increased hypothermia to prevent hypothermia trauma patients must be kept warm this is absolutely necessity all right so let's talk about shock you have to talk about shock when we're talking about the circulatory system so shock can result from many conditions including bleeding bleeding respiratory failure acute allergic reactions and overwhelming infection hypoblaming shock is shock from inadequate blood volume hypo means deficient vol means volume and emia is in the blood so a volume can be lost as blood plasma or electrolytes and hemorrhagic shock is most common cause of hemorrhagic shock is the most relevant due to blunt or penetrating injuries to vessels long bone or pelvic fractures or major vasovascular injuries so also multi multi multi-system injuries so organs and organ systems with high incidence of extenuations from penetrating injuries include the heart the thoracic vascular system the abdominal vascular system venous systems and the liver hypovolemic shock caused by hemorrhagic trauma is classified by the american college of surgeon committee for on trauma into four classes there's compensated shock and that's classes one and two decompensated shock that's class three and irreversible shock that's class four the table shows estimated fluid and blood loss for a 154 pound patient initial stage is characterized by low circulating blood volume and minimal signs of hypoperfusion as the body begins to compensate the patients begin to have tachycardia hypotension signs of poor tissue perfusion as oxygen supply to tissues this compromise and cellular metabolism is altered patients begin to become more confused and anxious and compensatory mechanisms continue to increase systemic vascular resistance leaving patients with cold or modeled pulseless extremities or worsening mental state if left untreated shock will progress to decompensated stage this table shows compensated versus decompensated",
        "Scene Size-up": "okay so now we're in the patient assessment part of the chapter and we begin of course with the scene size up and once the scene is deemed safe take standard precautions depending on the severity of the bleeding this may likely include the use of gloves mask eye shield and gown high energy mois should increase suspicion of internal bleeding it may include blood and penetrating trauma which may occur from falls last injuries automobile or motorcycle crashes and internal bleeding may also be caused by illnesses such as bleeding ulcers colon bleeding ruptured atopic pregnancies or aneurysms attempt to determine the amount of blood and remember presentation and patient assessment should direct patient care if sufficient mois scene time should not exceed 10 minutes so consider most appropriate transport decision",
        "Primary Survey": "determine the patient's mental status using apu and locate and manage immediate life threats to life involving the abcs apply the a before the b except after c for a patient with an active severe hemorrhage you may need to address the bleeding prior to initiating airway and respiratory measures ensure a patent airway and check breathing patterns chest wall integrity and pulse rate nss for hemorrhage shock if there is bleeding from the mouth or facial areas keep a suction unit ready and manage any major external hemorrhage immediately direct or entry for shock and transport to the emergency department direct pressure and pressure dressings can manage most external hemorrhaging arterial bleeding may take five or more minutes to form a clot and tourniquets can be effective can effectively control hemorrhage not responsible to or responsive to direct pressure and pressure bandage evidence support supports hemostatic agent use for external bleeding consult local protocols and studies are examining trans-ischemic acid or txa to help control internal bleeding a patient with internal hemorrhaging needs rapid transport to the emergency department tachycardia is an early sign of hypoperfusion suggesting internal hemorrhage late signs suggest internal hemorrhage include weakness thirst nausea vomiting cold moist or clammy skin dull eyes slightly dilated pupils that are slow to respond weak rapid pulse decreasing blood pressure bleeding can start again after it stops and if internal hemorrhage is suspected keep the patients warm and administered slap them supplemental oxygen by re-breathing non-review the mask at 15 liters a minute if minor external hemorrhage make note and complete the assessment manage after patient has been properly prioritized and when a patient has signs and symptoms of shock but only minor visible bleeding consider whether internal bleeding is occurring",
        "History Taking": "investigate the chief complain and obtain a history of the present illness ask about dizziness or syncope current medication that may thin blood history of clotting insufficiency the use of beta blockers calcium channel blockers and anti-just rhythmics or nitrogen and any pain tenderness bruising guarding or swelling",
        "Secondary Assessment": "perform a systemic full body scan the goal is to identify any injuries or illness that may have been missed during the primary survey symptoms of internal hemorrhage often include pain and swelling contusion or echomosis may also be a sign only initial sign of a pelvic or abdominal trauma may be redness or skin abrasions or pain so bleeding in the chest may cause dyspnea tachycardia hypotension and hemorrhage from any other body opening usually indicates internal hemorrhaging so signs of serious internal disease may or injury may include bright red bleeding from the mouth of the rectum or blood in the urine non-menstrual vaginal hemorrhaging note bleeding characteristics and try to determine the source other signs and symptoms of internal hemorrhage include hematomas so that's a mass of blood in soft tissue beneath the skin hema hemamesis and that's vomited blood molina that's black foul smelling or tar stool containing digestive blood it usually incur and it indicates a lower gi bleeding hematuria that's blood in the urine and pain tenderness bruising guarding or swelling it could indicate a closed fracture that is hemorrhaging possibly broken ribs or bruises over the lower part of the chest may indicate lacerated spleen or liver and may also have referred pain to the right shoulder that's the liver or left shoulder that's the spleen suspected internal abdominal bleeding in a patient with referred pain so assess the respiratory system check the airway for patency determine rate and quality of respirations and check for distended neck veins and a deviated trachea check for paradoxical chest movement and bilateral breath sounds and assess the cardiovascular system rate and quality of the pulses so pulse oximeter may be inaccurate for patients with shock vasoconstriction from the compensation for shock produces inaccurate readings of oxygen saturation use an ecg to monitor the cardiac rhythm and pulses are related to perfusion status so a blood pressure begins to drop pulses disappear blood pressure appears normal in the early stages of shock but as the patient moves from class 2 to class 3 shock medications may mask vital sign changes so beta blockers interfere with sympathetic responses channel blockers interfere with vasoconstriction and nitroglycerin interferes with vasoconstriction as well other anti-dysrhythmics interfere with the heart's ability to speed up or pump with more force so patients will often present with pale cool or modeled skin decreased or absent of the radial pulses and increase cap refill time assess neurologic system the exam should include the level of consciousness pupil size and reactivity monitor response and sensory response a trauma patient with an elevated blood pressure and a slow pulse may still be in shock but in response to a head injury the patient may be experiencing cushions to reflex which is an increasing intracranial pressure so assess all anatomic regions while examining the head look for raccoon eyes and battle signs and drainage of blood or fluid from the ears or nose while checking the abdomen feel for all four quadrants for tenderness and rigidity the extremities record the pulse motor and sensory functions and if the patient is bleeding from the extremities note the level of bleeding and whether the bleeding is arterial venous or pulsing",
        "Reassessment": "and then your reassessment so reassess especially where abdominal findings were found during the primary assessment in cases of severe hemorrhages obtain vital signs every five minutes in route to the emergency department so let's talk about the emergency medical care of bleeding and hemorrhagic shock you want to follow standard precautions if and suspect shock in cases of severe hemorrhaging you need to manage external hemorrhaging so to properly control external hemorrhaging in an extremity refer to skill drill 30-1 if signs of hyper perfusion exist transport rapidly provide aggressive management and route and provide psychological support hemorrhaging from the nose ears and",
        "Managing External Hemorrhage": "mouth so the ear and the nose is epistasis and that is it may indicate a skull fracture so do not attempt to stop the blood flow excessive pressure to the injury may force blood to collect in the head and increase intracranial pressure so cover the bleeding with loosely loosely with sterile god's pad and apply light compression by wrapping loosely around the head so if cerebral spinal fluid csf is present dressing staining will look like a bullseye target and glucometer will show high glucose levels in the blood nose bleed from other conditions so trauma to the nose or environmental factors apply a cold compress to the end of the nose or place a rolled gauze under the upper lip to generate pressure on the blood supply to the nose so always check blood pressure and evaluate for hypertensive emergency especially in older adults hemorrhaging from other areas so control through use of direct pressure we apply pressure dressings consider the use of a tourniquet or hemostatic dressing per local protocol use splints or air splints per local protocol and pack large gaping wounds with sterile dressing keep patients warm and in a the appropriate position and patience conditions should indicate the mode of transport",
        "Tourniquets": "so let's talk about special management techniques for external hemorrhaging tourniquets is what we're going to talk about first so especially useful if severe hemorrhaging from extremity injury below the axilla or groin and other methods are ineffective the laceration or tear of a large artery can cause a patient to exsanguinate in as little as two minutes you must be able to apply a tourniquet in less than 20 seconds tourniquets are no longer considered a last-ditch effort tourniquets have been proven so efficient and easy to use that the us military has issued tourniquets to all field personnel a number of commercially available tourniquets are marked including there's the mechanical advantage tourniquet and that's the matte tourniquet we have the combat application tourniquet that's a cat tourniquet also special operations forces tourniquet that's a soft t ratcheting medical tourniquet that's an rmt and a stretch wrap and turn again that's a swat t right to properly use a commercial tourniquet refer to your skill drill in chapter 30-2 okay this figure shows examples of commercially available tourniquets if a commercial tourniquet is not available apply tourniquet using a triangular bandage and a stick or rod fold triangular bandages to four inches wide and six to eight layers thick wrap bandage twice around the extremity at the area proximal to bleeding tie one knot in the bandage place a sticker rod on top of the knot and then tie the bandage ends over the stick in a square knot using the stick as a handle twist to tighten the tourniquet until the bleeding has stopped and distal pulses are not palpable secure the stick in place making the wrapping smooth right tk and the exact time applied on the adhesive tape and fasten the tape to the patient's forehead so blood pressure cuff can also be used as a tourniquet as well position the cuff one inch proximal to the bleeding inflate enough to eliminate distal pulses to stop the bleeding monitor the gauge constantly to ensure the pressure does not drop and you may have to clamp the tube with a hemostat keep in mind that blood pressure cuffs will leak and sometimes will not hold the pressure also a junctional tourniquet is used when the hemorrhage is in angular or axillary so a belt system holds the device in place and a pump inflates and compression device to put pressure on the deep vessels and when applied to the hips junctional tourniquet can also be used as a pelvic immobilization device there are precautions though do not apply a tourniquet directly over the joint it should be proximal to the zone of injury and use the widest bandage possible and ensure it is secured tightly never use a wire rope belt or a narrow material because it could cut the skin use wide padding underneath if possible never cover with a bandage you want to keep it in full view and inform the hospital of the tourniquet in the radio report and verbal report on arrival do not loosen the tourniquet after you apply it unless you're directed by hospital personnel or medical control",
        "Splints": "okay so broken bones can lacerate vessels muscles and other tissue this causes bleeding and may break up a partially deformed clot so mobilizing a fracture is a priority in prompt bleeding control okay so next we're going to talk about air splints we don't really use these where i'm from but they can control hemorrhage associated with venous bleeding and stabilize fractures it acts like a pressure dressing applied to an entire extremity and once applied distal monitor distal circulation it's typically inflated to about 50 millimeters mercury so not appropriate for use for arterial hemorrhage and i use only approved clean and disposable valve stems so rigid splints they help stabilize fractures and reduce pain monitor of course distal extremity circulation also there's traction splints they could stabilize femur fractures traction is pulled to the anchor ankle and a counter traction is applied to the groin area pad the area as well to prevent excessive pressure to soft tissue pelvis and then monitor the distal extremity circulation",
        "Hemostatic Agents": "next we're going to talk about hemostatic agents so these are used to control severe hemorrhage especially to areas where tourniquets cannot be applied such as junctional wounds and this causes enhanced clot formation in the wound site they adhere to damaged tissue and either dehydrate the blood or undergo a chemical reaction that stimulates the natural blood clotting cascade so hemostatic agents should share a few common atrophy attributes so they're lightweight lightweight and easy to store carry and deploy they conform to the wound itself allowing the agent to work where it's needed they can withstand the high pressure or flow of bleeding wound they cause little no damage to the tissues they're easy to remove from the wound and they do not spread into the rest of the system as small particles their prevalent agents on the market are gauze and pregnant with various clotting agents complications with the use of hemostatic agents available in powder form include introduction of emboli through the open vasculature and introduction of foreign substance into the wound next we're going to talk about wound packing so particularly helpful in bleeding from or in junctional areas such as the groin or axilla where tourniquets cannot be used and it works by absorbing liquid from the blood and helping to concentrate clotting factors if using hemostatic dressings it can also chemically accelerate the clotting process so wound packing involves a process of first the standard initial steps is to control the bleeding with direct pressure and push the guys into the wound with your index finger to pack the wound cavity if excess extra gauze is left over place it on the wound and hold firm direct pressure on the wind for at least three minutes to secure the wound with a snug pressure dressing over the wound",
        "Managing Internal Hemorrhage": "so managing internal hemorrhaging focuses on treatment of shock and minimizing movement of the injured or bleeding part of the region and rapid transport eventually surgery will be needed to stop the bleeding in recent years ultrasound is used to locate bleeding before surgery to properly control internal hemorrhaging refer to skill drill 30-3 treatment so give the patient nothing by mouth and you need to insert an 18 gauge catheter and administer a fluid bolus of 250 milliliters of saline or lactated ringers without delaying patient transport establish a second 18 iv line if possible whenever possible use warm fluids consider giving pain management if the patient's vital signs are stable provide immediate transport and monitor the cereal vital signs if the patient shows any signs of hypoperfusion transport rapidly and provide physiological support",
        "Management of Hemorrhagic Shock": "so management of hemorrhagic shock the priorities are the same as for the patients with focus on the cabs always take standard precautions identify and treat try to stop the major bleeding establish and maintain the airway comfort calm and reassure the patient in a supine position do not allow the patient to eat or drink splint the patient on a backboard and immobilize injuries as needed if the patient exhibits signs and symptoms of shock administer supplemental oxygen keep the patient warm and prepare for transport and route to the ed insert at least one and preferably two 18 gauge peripheral iv lines using an over the needle catheter if hemorrhage is suspected blood products should be started early they will require typing and cross match in an emergency department acs recommends blood products for class 3 and 4 hemorrhage after an initial 2 liters of isotonic solution do not give anything by mouth keep the patient at normal temperature and monitor the ecg rhythm for dysrhythmias the state of consciousness blood pressure and pulse okay so that concludes this chapter um bleeding chapter 30. thank you for joining us today and we hope you enjoyed the lecture"
    },
    {
        "Introduction": "hello and welcome to chapter 34 head and spine trauma lecture in this chapter you will learn about",
        "Injury to the Central Nervous System": "injury to the central nervous system the central nervous system consists of the brain and spinal cord both of which are encased in and protected by bone the brain located in the cranial cavity is the largest component of the central nervous system it contains billions of neurons that serve a variety of vital functions and understanding a form and function of the spinal anatomy and a high index of suspicion for spinal trauma injury is essential to good patient care with this type of traumatic injury okay so let's get started the central",
        "Central Nervous System": "nervous system like i mentioned on the last slide consists of the brain and spinal cord there are two primary divisions of insult that could occur and",
        "Head Trauma": "there's head trauma and then there's a spinal cord injuries okay so let's talk about the head trauma it's a general term that just includes both head injuries and traumatic brain injuries so a head injury is a traumatic insult to the head that may result in injury to the soft tissues of the scalp or bony structures of the head and skull not including the face and a traumatic brain injury is an impairment of the brain function caused by an external force that may involve physical intellectual emotional social and vocational changes so spinal cord injury that's an injury of the spinal cord such as ischemia or bruising fracture or severing that disrupts normal spinal cord functions the head and spine are often injured in association with each other okay so let's do some anatomy and",
        "Anatomy and Physiology": "physiology review first thing we're",
        "Scalp": "going to talk about is the scalp and the scalp is composed of multiple layers you have subcutaneous tissue that contains major vessels that bleed when lacerated and then you have superficial fascia and that is attached to the vessels do not underestimate the blood loss potential from scalp hemorrhaging and do not get distracted though from other life-threatening injuries okay next is",
        "Skull": "the skull it consists of 28 bones that make up the cranium auditory ossicles in the face the cranial vault it's a eight flat irregular bones it generates blood cells it protects the brain by directing impacts around it and it provides a container for the brain cerebral spinal fluid and blood and the hematoma would increase in our cranial pressure and that's known as icp this figure shows the bones of the skull okay so the floor of the cranial vault consists of several ridges and depressions that have openings that allow nerves to exit the skull when it comes to coup contra coup injury the brain impacts two sides of the skull lacerations from skull floor can occur in contusions from contact with frontal and occipital bones okay so the base of the skull it consists of parts of the ethmoid cephenoid occipital frontal and temporal bones and it's when it comes to basilar skull fracture it can involve the temporal bone and it's revealed in the field by drainage of central or cerebral spinal fluid from the nose or the ears and the most common location of drainage is the nose and that indicates a fracture of the ethmoid or the temporal bone okay so the next thing we're going to",
        "Brain": "talk about is the brain it contains billions of neurons that serve various vital functions the major regions are the cerebrum the brain stem and the cerebellum it accounts for two percent of body weight and it's the most metabolically active and perfusion sensitive organ in the body it's completely reliant on a consistent and constant source of oxygen and glucose via cerebral blood flow loss of blood flow for 5 to 10 seconds will result in unconsciousness so first let's talk about the",
        "Cerebrum": "cerebrum it's the largest portion of the brain it's responsible for higher functions such as reasoning it's divided into the right and left hemispheres the",
        "Cerebral Cortex": "cerebral cortex is the largest portion of the cerebrum it regulates voluntary skeletal movement and level of awareness injury may result in paresthesia weakness and paralysis of the extremities each hemisphere is divided into specialized areas called lobes the",
        "Frontal Lobe": "frontal lobe is important to voluntary motor action and personality traits injury could result in seizures or placid reactions so that's a flat effect it filters the raw emotional impulses from the limbic system an injury to the frontal lobe may result in a personality change in the patient the parental lobe processes information from sensory receptors in the skin and joints it governs the perception of pain temperature and vibration it is also responsible for the ability to perceive position and movement of one's body or limbs injury to this low may prevent patients from calculating two plus two or knowing how many dimes are in a dollar",
        "Occipital Lobe": "the occipital lobe processes visual information a blow to the back of the head causes one to sea stars in the temporal lobe control speech long-term memory hearing taste and smell",
        "Cerebellum": "then there's the cerebellum so it's located beneath the cerebral hemispheres in the inferior posterior part of the brain sometimes called the athlete's brain it's responsible for maintenance of posture equilibrium and coordination and injuries can prevent the patient from performing rapid alternating alternating movements and then there's the brain stem it consists of the midbrain pons and medulla it's located in or at the base of the brain it connects the spinal cord to the rest of the brain and it houses many structures crucial to vital functions okay",
        "Meninges": "the meninges so the meninges are a protective layer that surround and enfold the entire central nervous system the dura mater is a strong fibrous outer layer it covers the brain and it's formally attached to the internal wall of the skull it splits into two surfaces and forms the venous sinuses any injury to these sinuses can cause a subdural hematoma you have the arachnoid it's a delicate transparent second layer and then the pia mater that's the thin translucent and the highly vascular third layer the pia mater adheres directly to the surface of the brain between each of these layers is the potential space in which bleeding can occur okay so let's talk about the different types of bleeding an epidural hematoma occurs between the dura mater and the skull and is usually caused by rupture of a metal meningeal artery okay a subdural hematoma it occurs between the dura mater and the arachnoid membrane and is all usually caused by a rupture of the bridging veins in the space then you have this subarachnoid hemorrhage and that occurs below the arachnoid membrane",
        "The Spine": "the spine so it consists of 33 bones or vertebrae divided into five sections it's stabilized by ligaments and muscles and supports and protects natural elements so it will it allows for fluid movement and an erect stature the vertebral bottom body bone and supports and stabilizes the body basic characteristics shared by the vertebrae so expect the atlas and axis in c1 and c2 and separation and cushioning of each vertebra by intervertebral disc as the body ages these discs become thinner and that causes height loss associated with aging so stress on the vertebral column can cause discs to herniate into the spinal canal this may result in injury to the spinal cord or nerve rot so the vertebral column can sustain normal flexation and extension of 60 to 70 percent without stressing the spinal cord",
        "Spinal Cord": "now let's talk about the spinal cord so that it transmits nerve impulses to the brain and the body it's located at the base of the brain it leaves the skull through the form magnum it separates at the base of the skull there are 31",
        "Spinal Nerves": "pairs of spinal nerves that emerge from different segments of the spinal cord c1 through 2c 7 exit the spinal cord above their respective vertebrae see c8 exits below the c7 vertebrae all the other spinal nerves exit the spinal column below below the respective vertebra for which they are named",
        "Spinal Nerve Groups": "okay so the spinal nerve groups are named based on the source of origin and point of termination okay so converge into plexus that enables several spinal cord nerves to control one area of the body so one example is",
        "Cervical Plexus": "the cervical plexus so c1 through c5 and then the phrenic nerve so c3 through c5 also arises from plexus and contains nerves that supply the diaphragm you have the brachial plexus that's c5 through t1 it joins nerves controlling the upper extremities the lumbar plexus that's l1 through l4 supplies the skin and muscles of the abdominal wall external genitalia and part of the lower limbs and then you have the sacral plexus that's l4 through s4 it gives rise to the sciatic nerves supplies the buttocks perineum in most of the lower limbs okay so when you talk about the nervous system you need to talk about the",
        "The Sympathetic Nervous System": "sympathetic nervous system and this system mobilizes the body for activity the brain transmits information through the brainstem and the spinal cord okay",
        "Sympathetic Nervous System": "so the sympathetic nervous system controls sweating pupil dilation temperature regulation and the fight or flight responses loss of the sympathetic stimulation can disrupt homeostasis which leaves the body poorly equipped to deal with changes in the environment",
        "Parasympathetic Nervous System": "and then there's the parasympathetic nervous system this includes fibers arising from the cranial and sacral nerves and it carry signals to the organs of the abdomen heart lungs and skin it slows heart rate in an attempt to control increasing blood pressure when the sympathetic nerves are stimulated okay so let's go into the patient",
        "Patient Assessment": "assessment recognition of the presence of a brain injury and beginning immediate care so scene size up you want to assess scene safety and consider the need for additional resources the following event should prompt a search for signs and symptoms of head and traumatic brain injury so a motor vehicle accident or a direct blow or fall from heights assault or sports injuries and or high velocity crashes so we're talking greater than 40 miles an hour with severe vehicle damage this is um these indicate the need for full spinal immobilization okay an unrestrained occupant of a moderate to high speed mba vehicular damage in the compartmental intrusion of 12 inches into the patient's seating space a fall of an adult from a height greater than 20 feet or fall of a child from a height of 10 feet or greater and penetrating trauma near the spine those definitely need to have full spinal motion restriction applied also ejection from an mva motorcycle crash of greater than 20 miles an hour adult pedestrian or auto bicycle crash of greater than 20 miles an hour death of an occupant in the same passenger compartment or a rollover crush which is restrained so ensure manual stabilization of the cervical spine in a neutral in line position you need to determine the level of consciousness and conduct your primary survey apply cervical collar if your",
        "Cervical Collar": "findings require it but first assess the abcs and the pulse motor and sensory functions prior to measuring the patient for cervical collar the cervical and thoracic spine must be in the neutral position so do not let the patient slouch when you're measuring that so ensure the open airway and be prepared to roll patients onto their side to prevent aspiration if local protocols allow a nasal airway use caution and because um of the possibility of you know the skull fracture and nasal fracture though too as well you should not use it an advanced airway management patients with a header spine injury so maintain manual stabilization during all airway management procedures and nasotracheal innervation carries the risk and is generally contraindicated when you have any type of head injury so whenever possible use another method and if the patient will tolerate an advanced airway um or will not tolerate due to combativeness or clenched teeth you need to consider pharmacologically assisted innovation so rapid sequence innovation okay so when it comes to ventilation in",
        "Ventilation": "context of a head or spine injury you need to ensure adequate oxygenation and ventilation in any patient with a head injury do not defer oxygenation until you're in route if there are signs of hypoxia administer 100 oxygen via non-rebreather if the patient's breathing adequately and administer a bag valve mask and 100 oxygen for patients with inadequate ventilation so oxygen should flow at a rate of 12 to 15 liters a minute and optimally you should ventilate the patient to maintain the end tidal between 35 and 40. okay so if you cannot monitor entitle then a respiratory rate of 10 to 12 breasts per minute in an adult patient will achieve the target rate you need to avoid the routine hyperventilation the brain trauma physician foundation so that's the btf recommends hyperventilation only if signs of cerebral herniation are present so the recommended rates of hyperventilation are an adult is 20 breasts per minute child is 25 and an infant which is of course younger than one year old it's 30 breaths per minute",
        "Circulation": "next is circulation so in the absence of a pulse of course immediately initiates cpr control major bleeding with direct pressure gauze hemostatic agents or pressure dressings and do not apply excessive pressure though to the scalp lacerations in which an underlying fracture is suspected examine skin color temperature and moisture so patients with significant sensory loss may take us on the surrounding environmental temperature so patients with neurogenic shock will have skin that is warm dry and flushed because of the vasodilation or the dilated blood vessels in the absence of sweating volume resuscitation might be necessary if there is an absence or diminished pulse so estimate at least or establish at least an 18 gauge with normal saline or lactated ringers and do not administer dextrose containing solutions because they may worsen cerebral edema restrict your use of iv fluids for patients with a severe closed head injury if patients in pure neurogenic shock may need some type of vasopressors so use a cardiac monitor with every critically injured patient and consider transcutaneous patient pacing for refractory symptomatic bradycardia re-evaluate the patient's mental status in response to stimuli and note any changes since your initial contact with the patient check for presence of a pulse evaluate monitor sensory function in each extremity and directly observe the back to assess for penetrating trauma palpate the patient's spinal cord for deformity step offs point tenderness and crepitus and use the information to determine whether the patient needs spinal immobilization so with head trauma and traumatic brain injuries the pupils can reveal valuable information about the patient in his or her condition so consider performing a quick baseline assessment through the disability portion of your primary survey remove any clothing that would obstruct your secondary assessment so cover the patient with a blanket though as needed to maintain that normal body temperature and then the level of consciousness so when you suspect a head injury you need to perform a baseline neurological assessment using apple and record the time and then obtain a glasgow coma score a change in the level of consciousness is the single most important sign that you can detect when you assess the severity of a brain injury level of consciousness usually indicates extent of brain dysfunction so formulating a plan prompt transport to the trauma center is crucial to the survival of the patient consider air transport if transport time will be long and if transporting by ground do so quickly and cautiously many patients will require a neurosurgical intervention and transfer the patient directly to the trauma center with neurosurgical services this could be the difference between life and death for the patient",
        "Placement on the Backboard Spinal Immobilization": "so placement on the backboard spinal immobilization of the patient may involve a backboard a scoop stretcher or a similar device the timing of this action is based on the condition of your patient so for critical patients apply the immobilization after the primary survey to enable rapid transport for a non-critical patient apply the immobilization after the secondary assessment and most patients can be log rolled while you watch for deformity or injury and palpate over each posterior spinous process for pain deformity or step-offs a reliable patient meets the following conditions is he alert and oriented has no language barrier has no evidence of brain injury or toxication or has no alteration in his or her ability to make the decisions or recognize pain and injury in reliable patients the following may eliminate the need for spinal mobilization the absence of pain or tenderness along the spine a neuromoral neurological exam and the absence of distracting injuries always protect paralyzed limbs with appropriate restraint and stretch immobilization so patients in severe pain may require an alternative method to transport transfer them to the long backboard you could use a scoop stretcher to lift the patient other crew member can slide the backboard or air mattress or vacuum mattress under the patient you could also choose to use the scoop stretcher alone without transferring the patient to the backboard or other device the time on the backboard should be limited because skin breakdown can be a complication of full spinal immobilization so conditions caused by excessive pressure over the primary supports for the patient's weight so they're on the bones of the buttocks or the scapular ridges or the base of the occipit there are several devices and they've been developed to improve patient comfort these are the vacuum mattresses or back rafts and concave backboards okay so this photo shows the placement of a patient on a backboard and the back raft so this takes pressure off specific areas of the back and uh you fill voids that might otherwise allow patient movement so towel rolls and blankets to void pad voids between the patient and the backboard and and then there's concave backboard so they conform more closely to the patient's anatomy than do flat backboards",
        "History Taking": "all right so history taking patient's reliability should be assessed so patients should be considered unreliable if they present with an acute stress reaction distracting injuries or alteration in their mental status due to brain injury or intoxication maintain a high level or index of suspicion treat all patients who experience major trauma above the clavicle or who are found unresponsive as if they have a spinal injury obtain a sample history you want to use the signs and symptoms of the current complaint circumstances of the incident and forces to which the patient was subjected so blunt or penetrating trauma flexation injury torsion of the neck in the case of the fall you want to know the height of the fall or was anything struck on the way down how did the patient land and what did the patient land on in a case of the vehicular crash you want to use the position of the restraints positions position in the vehicle and the degree of damage on the vehicle also the time of the initial injury and any change in the patient's presentation when it comes to the secondary",
        "Secondary Assessment": "assessment you want to modify the physical exam of any patient with a suspected spinal cord injury so you want to know the level of consciousness the reliability as a historian and the mechanism of injury in case of high or intermediate risk mechanisms when the patient has not already been immobilized complete the physical exam with the patient in the neutral position without moving the spine apply manual stabilization you could ask the patient not to move unless asked or administer sedation or rsi procedures depending on the patient's ability to protect their airway it's mostly for a combative patient thoroughly assess the head and face for soft tissue injuries or bone instability depression or drainage from the nose or ears also you're looking for echomosis or battle signs and or paraorbital echomosis and that's bruising under the eyes and that's raccoon eyes okay so reevaluate these areas if the cervical collar is not in place and frequently monitor the pupil size shape quality and reactivity also assess both the direct and pupil response to light so a sluggish pupil is an early sign of increased intracranial pressure it also could indicate cerebral hypoxia if the patient is conscious evaluate extraocular movements and evaluate the chest and abdomen for both internal and external injuries as well monitor the cardiovascular system for signs of shock in male patients assess for priapism and look for abnormal posturing obtaining glucose level in patients who show evidence of alterations in sensations so assess increase intracranial pressure so icp cannot be quantified in the pre-hospital setting but severity of increases can be estimated crucial treatment decisions are based on the presence or absence of key findings such as posturing hypotension or hypertension or abnormal pupil signs use cereal glass glacoma scores and pupillary assessments to monitor the progression of icp in the neurologic exam so it's intended to establish a baseline for later comparison and to determine whether to immobilize the patient all right so determine the level of consciousness and note the af poo in the primary and then address the glasgow coma score level during further assessments okay so myotomes are regions",
        "Myotomes": "in the body where the motor components of the spinal nerves supply specific tissues and muscles you need to bilaterally assess each major motor group from top down so when you ask the patient to flex that's going to be c5 involved and extend is c7 both elbows and then wrists are c6 ask the patient to add abduct and adduct his or her fingers against resistance and that's t1 ask as an alternative to the patient to curl the fingers while applying resistance that's c8 ask the patient to bend and extend their knees and the patient to ask the patient to plant or flex at the feet and ankles that's s1 and s2 and dorsiflex the toes to gravity and resistance that's l5",
        "Motor Integrity": "the motor integrity in a unresponsive patient can be assessed via response to painful stimulus so test on several locations before assuming an absence of response okay so these photos show the steps of a neurologic evaluation of the upper extremities and then these show the evaluation of the lower extremities",
        "Dermatomes": "dermatomes are regions of the body where sensory components of spinal nerves supply specific areas of the body surface so test general loss of sensations and ask about abnormal sensations so pins and needles or electric shock feeling assess sensory integrity bilaterally from the feet up so identify the lowest level of normal sensation and assess the patient's perception of a light touch or temperature and position okay reflexes can provide valuable information about the sensory input and so specific reflexes are usually absent but return several hours or weeks later and if reflexes are intact preservation of motor and sensory activities is likely",
        "Babinski Reflex": "a positive babinski reflex occurs if the toes move upward in response to the stimulation of the soles of the feet you want to reassess it's necessary to determine whether the patient is stabilizing improving or deteriorating and monitor vital signs every 5 for the unstable and 15 for the staple and be alert for hypotension without other signs of shock okay check your interventions and repeat the physical exam and re-prioritize the patient and document suspected spinal cord injuries head trauma comprises both head injury and traumatic brain injury head injury is traumatic insult to the head with injury to the scalp or the skull not including the face or brain traumatic brain injury is an impairment of the brain function brought about by external force such as a fall",
        "Traumatic Brain Injury Statistics": "so traumatic brain injury statistics according to the centers of disease control and prevention traumatic brain injury is responsible for 30 percent of trauma-related deaths each year 2.8 million visits to emergency departments 282 000 hospitalizations and 50 000 deaths from 2007 to 2013 traumatic brain injury-related emergency department visits increased by 50 percent but the number of deaths decreased by seven",
        "Causes of Traumatic Brain Injuries": "so causes of traumatic brain injuries include 47 percent our falls uh 15 is unintentional unintentional blood trauma and then motor vehicle is 14 and unknown is 25 or 24 okay so causes of traumatic brain injury by group um greater than 65 years or older are falls on 25 to 64 is intentional self-harm and motor vehicles accidents are five to 24 year olds below is uh zero to four year olds it's assault",
        "General Types of Head Injuries": "so general types of head injuries just like any other trauma is uh that's two categories it's open or closed now closed are the most common they're associated with blood trauma and dura matter and damage and brain tissue is not exposed it results in a skull fracture or traumatic brain injuries and it may be focal or diffuse so focal is limited to the focused area and diffuse is diffused spread out with increased intracranial pressure an open type of head injury is associated with a penetrating mechanism such as gunshot wounds it's the most common and the highest mortality rate penetration of the dura mater and cranial contents the brain tissue move to the environment so let's talk about some",
        "Pathophysiology of Head Injuries": "pathophysiology of head injuries when",
        "Scalp Injuries": "you have scalp injuries the scalp comprises of what five layers and the rule of the scalp is the following so it protects the head from the outside organisms it provides thermal regulation and controls the loss of extracellular fluid through evaporation variations from minor to serious scalp lacerations occur even small lacerations though can lead to significant blood loss due to the scalp's rich blood supply so do not be distracted though by the injury at risk of missing an underlying injury and hypovolemic shock in adults is rare",
        "Scalp Lacerations": "rarely caused by scalp lacerations alone though scalp lacerations often indicate a deeper more serious injury consider the mechanism when it comes to the scalp injuries you want to inspect four indications of missing tissue or impelled objects or some type of contaminant and evaluate for signs of continued bleeding and re-evaluate often in isolated lacerations you want to stop the bleeding apply direct pressure and pressure dressings and if time and other injuries do not prevent it a quick cleaning rinse can reduce the incidence of infection but do not explore the injury this may disrupt the clot formation and restart bleeding",
        "Skull Fracture": "when it comes to skull fracture they're significant related to the type of fracture the amount of force and the area of the head that sustain the blow potential complications include intracranial hemorrhaging cerebral damage and cranial nerve damage",
        "Four Types of Skull Fractures": "we're going to talk about the four types of skull fractures and the very first one we're going to talk about is the linear skull fracture",
        "Linear Skull Fracture": "and this is a non-displaced fracture and think of the linear as the line right it accounts for the majority of all skull fractures and it most likely occurs in the temporal parental region of the skull radiographic evaluation is needed for diagnosis so you need an x-ray because usually you won't be able to feel it the lineal skull fracture but when it comes to the depressed skull fractures you're going to be able to feel it not that you want to press on it but they result from high energy direct trauma to a small surface area of the head with a blunt object the frontal and perennial regions are most susceptible because the bones are relatively thin patients often present with neurologic signs so like a loss of consciousness and these fractures have the greatest association with patient death",
        "Basilar Skull Fractures": "basilar skull fractures they're associated with high energy trauma but usually occur following diffuse impact to the head they can be difficult to diagnose without an x-ray and then you have the open skull fractures they result they're a result of severe force being applied to the head often associated with trauma to multiple body systems exposure brain tissue to the environment and they have a high mortality rate",
        "Assessment and Management of Skull Fractures": "so the assessment and management of skull fractures is what we're going to talk about next and you want to use the pads of your fingers to apply pressure over the entire skull",
        "Basilar Skull Fracture Signs": "the basilar skull fracture signs you're going to have the central nervous system or csf fluid draining from the ears or nose and a pair orbital echomosis that develops around the eye so that's raccoon eyes and then eccomosis behind the ears and that's the battle sign but that echomosis behind the ear the battle sign it may not appear for up to 24 hours after the injury all right so identify and treat all life threats and provide manual inline stabilization of the cervical spine and then provides supportive care for linear skull fractures so traumatic brain injury is classified into primary brain injury or secondary brain injury the primary injury to the brain when that is the injury to the brain and its associated structures and it results instantaneously from the impact to the head",
        "Secondary Brain Injury": "when it comes to the secondary brain injury it is the consequence of the primary it includes abnormal processes such as cerebral edema or inner cranial hemorrhaging increased icp or cerebral ischemia hypoglycemia or hypotension or infection it can last anywhere from a few minutes to several days following the initial injury",
        "Motor Vehicle Accidents": "so motor vehicle accidents the most common cause of brain injuries are coup contracous so that's the front and rear type of injury the passenger's head hits the windshield on impact and the brain continues to move forward until it strikes the inside of the skull then the head falls back against the head rest and the brain slams the rear of the skull this type of injury may occur on opposite sides of the brain in a lateral crash so the injured brain starts to swell because of the dilated cerebral vessels and an increase in cerebral fluid so cerebral edema inner cranial pressure so to function properly the brain needs a constant supply of oxygen and nutrients such as glucose blood flow through the brain so that's the cerebral blood flow flow must be maintained at a constant level an increase in icp can be caused by accumulation of blood within the skull or swelling in the brain increased icp squeezes the brain against the bony promises within the cranium",
        "Cerebral Perfusion Pressure": "cerebral perfusion pressure equals the difference between the mean arterial pressure and icp the map is this diastolic blood pressure plus one third of the pulse pressure the normal icp is 5 to 15 milli millimeters of mercury and the normal map is 85 to 95 millimeters of mercury any increase in icp above 20 millimeters of mercury decreases the cpp and cerebral blood flow the body responds to decrease in the cpp by increasing the map this process is known as auto regulation",
        "Auto Regulation": "the brain can audio regulate and ensures adequate cerebral blood flow when the cpp is between 60 to 160 millimeters of mercury the crucial minimal threshold is at 60 in an adult if the cpp is less than 60 this leads to cerebral ischemia and if the cpp is greater than 160 it produces hypertensive encephalopathy in an effort to combat increasing intracranial pressure the body uses this monroe kelly doctrine so in response to an expanding intracranial mass the body reduces intracranial pressure by expelling csf and venous blood from the cranial vault the mechanism keeps the icp within normal limits in early stages so when the in icp begins to rise and the cpp begins to drop the body attempts to maintain the cpp and increasing the map so it's to recognize this pattern you must auscultate blood pressure noting both the systolic blood pressure and diastolic other factors interfere with cpp so excessive carbon dioxide in the blood hypotension swelling and bleeding so pre-hospital treatment should focus on maintaining the cerebral blood flow while mitigating increased intracranial pressure so with when it comes to herniation if increased intracranial pressure is not treated properly the cerebral herniation may occur",
        "Lateral Herniation Syndrome": "so lateral herniation syndrome is the most common form of herniation this is when a portion of the temporal lobe is displaced laterally it then moves downward through the um basically the brain stem and it compresses the midbrain and posterior cerebral artery",
        "Signs of Herniation": "signs of herniation include pupil dilation opposite side or motor dysfunction and central herniation syndrome occurs when the brain tissue shifts downward ultimately compressing the brain stem from above brain stem compression destroys the respiratory center inducing apnea decreasing perfusion to the rest of the brain and ultimately causing death these patients require immediate surgery to place a drain early signs and symptoms of increased endocranial pressure include vomiting or a headache altered level of consciousness or seizures and later signs of icp include hypertension widening pulse pressures bradycardia or changes in respirations and that's the cushing's triad so the cheyenne stakes stokes respirations and basically it's efforts to reduce the partial pressure of carbon dioxide unequal pupils or non-reactive pupils or coma or posturing okay so this figure shows posturing and it indicates a significant intracranial pressure the top one you have decorticate and that's a coring in and the bottom one is disarabic and that's a posturing out when you talk about diffused brain",
        "Diffused Brain Injuries": "injuries they affect the entire brain",
        "Cerebral Concussion": "it's also known as a cerebral concussion and the brain is basically jarred around in the skull it's caused by rapid acceleration or deceleration forces and these forces damage the cell membranes of the neurons which depresses neural activity uh basically you the signs and symptoms are a headache confusion disorientation or loss of consciousness you could have retrograde amnesia anterior-grade amnesia retrograde of course as before anterior greatest as after the loss of the memory relating to the actual events that occurred okay so as a paramedic you probably will treat patients who have experienced a",
        "Concussion": "concussion concussions are cause more than one million emergency departments annually visits and so it's estimated that there are about 1.6 to 3.8 million sports related concussions annually suspected concussion even when the helmet is used athletes athletic venues are a common side of concussions and most youth coaches are required to take concussion training assessment and management include complete the primary survey and address any life threats secondary assessment is directed at evaluating for the presence of a concussion so if you suspect a concussion you must complete a thorough evaluation and you're going to assessment of will focus on the prime primarily on cognition patient history is key component and ask your patient questions to assess his or her memory and awareness of person place time and situation",
        "Findings of a Concussion": "findings of a concussion include a headache that's the most common finding fatigue or fogginess confusion or altered mental status and ability to recognize people or places maybe disorientation or dizziness or difficulty concentrating or memory deficits difficulty maintaining balance or visual disturbances or develop delayed responses to questions or irrita irritability changes in behavior sleep disturbances so there's a lot of them several assessment tools and skills can help you identify a possible concussion so there is an acute concussion evaluation tool from the cdc and the emergency treatment of the patient with an isolated concussion is as follows so primarily support and manual physical physical and mental rest so if the patient refuses transport obtain a refusal and your system may require you to contact medical control so give the patient specific cdc information",
        "Second Impact Syndrome": "a second impact syndrome ask the patient about recent concussions second impact syndrome is rare it's often fatal result of receiving a second concussion while still recovering from an earlier one the brain is still vulnerable and minimal force can result in an increased cerebral blood flow brain herniation and death so death can occur in two to five minutes after that injury so signs and symptoms are sudden loss of consciousness after that blow a stunned appearance or dilated pupils coma or respiratory failure the emergency department of second impact syndrome is supported the treatment of it and the second concussion that occurs within seven to ten days of a previous concussion necessitates immediate transport to the closest facility with a neurosurgical capability",
        "Post-Concussion Syndrome": "post-concussion syndrome so the patient may experience signs and symptoms for three to six months after the initial concussion this differs from second impact in that it is a result of the original concussion not a second one and it requires the patient to be transported for evaluation by a physician post concussion syndrome should be suspected when a patient has at least three of the following symptoms for at least three months after the concussion so headache dizziness fatigue irritability insomnia difficulty concentrating memory difficulty or intolerance of stress or motion okay so we're going to talk about",
        "Diffuse Axial Injuries": "diffuse axial injuries next it's one of the most common diffuse brain injuries has a high mortality rate it's the most common cause of post traumatic unconsciousness and the most common cause of persistent vegetative state after a traumatic brain injury it involves stretching shearing tearing of nerve fibers and axial damage so it's caused by high speed or rapid acceleration or deceleration forces and it's classified as mild moderate or severe okay so assessment and management",
        "Assessment and Management": "the primary finding is unresponsiveness it could last for more than six hours treatment is the primary supportive and be wary of airway compromise perform primary survey and address the life threats patients should be transported to the closest facility with in-house neurologists so when you talk about specific grossly observable brain injuries the first one we're going to talk about",
        "Cerebral Contusion": "is a cerebral contusion and that's when the brain tissue is used bruised and damaged in a local area there's greater neurologic deficits are observed with with this than the concussion the frontal lobe is most commonly affected swelling of the brain leads to increased intracranial pressure",
        "Intracranial Hemorrhaging": "intracranial hemorrhaging so there's a couple of them that we're going to talk",
        "Epidural Hematoma": "about is an epidural hematoma and that's an accumulation of the blood between the skull and the dura mater happens in half a percent to one percent of all head injuries there always results from a blow to the head ordinarily there's an immediate loss of consciousness and then a brief lucid level and then another loss of consciousness all right so there's a high survivability with early treatment and other signs and symptoms are limited to those of the associated concussion and any soft tissue damage or crepitus to the area of impact so that's the epidural and then the",
        "Subdural Hematoma": "subdural hematoma is an accumulation of blood beneath the dura mater outside of the brain this is the most common intracranial hemorrhage it's associated with venous bleeding icp develops more gradually so it's a slow venous bleeding patients often experience a fluctuating level of consciousness and slurred speech it is classified as acute subacute or chronic okay",
        "Intra Cerebral Hematoma": "and then there's intra cerebral hematoma so this is the third one and this is uh results from a penetrating trauma to the head or from rapid deceleration forces many are associated with other brain injuries such as a diffuse axial injury and the patient's condition deteriorates quickly and there's a high mortality rate with this even with surgery and then there's a subarachnoid hemorrhage so subarachnoid hemorrhage is bleeding in the subarachnoid space this results in bloody csf and menin meningeal irritation so it causes include trauma or ruptured rupture of an aneurysm the patient typically presents with sudden severe headache as deep as bleeding increases signs and symptoms of increase in neocranial pressure develop okay so the last two we're going to talk",
        "Subgalleo Hemorrhage": "about is the subgalleo hemorrhage this is the first one and it can result in enough blood loss to precipitate hypovolemia in infants and then you have",
        "Supra Galil Hemorrhage": "the supra galil hemorrhage and that's a firm nodular mast it's known as a goose egg usually used to describe it so when you talk about considerations and factors such as the severity of the injury and the patient's level of consciousness treatment priorities must be based on the conditions that will kill the patient first so always check for breathing pattern and rate and determine the if the patient has abnormal bleeding pattern breathing pattern watch closely for signs of increased intracranial pressure and ensure time on scene does not exceed 10 minutes maintain an open airway and ensure the patient's breathing is adequate",
        "Thermal Management": "thermal management is is important for the assessment and management so do not allow the patient to develop um a high body temperature so it can worsen the condition of the brain and do not cover the patient with blankets if the ambient temperature is 70 degrees or higher so pharmacological therapy is usually not indicated for brain injury patients it may be ordered if transport will be prolonged though seizures must be terminated as soon as possible benzodiazepines should be used first and no neuroprotective agents are currently administered in the pre-hospital setting so when it talks about the pathophysiology assessment and management of spinal injuries limited treatment option and heavy reliance on rehab over the acute intervention so reducing incidence is the best option for decreasing associated mortality and morbidity in the united states there's 17 000 new cases each year high mortality rates are the highest in the first year after the injury and the leading cause of death for the sci patients are after they're discharged from the hospital is pneumonia or a pulmonary emboli or sepsis",
        "Mechanism of Spinal Injuries": "mechanism of spinal injuries so um the force that causes the injury to the spinal cord anytime you suspect a spinal injury you should assess whether the spinal injury is or spinal immobilization is necessary also the medical history so the patient's age factors associating with decreased bone density such as alcohol abuse or cigarette smoking diabetes and then also common locations so most spinal cord injuries occur in the area of the cervical spine and the most the next most common is the lumbar region there are flexation injuries so flexation injuries result from the forward movement of the head at c1 to c2 level farther down the spinal cord forces can result in an interior wedge fracture hyperflexion injuries are of greater force and can result in tear drop fractures and then patients can experience lateral bending as well",
        "Rotation with Flexation": "okay the next is rotation with flexation the area only area of the spine that allows for the significant rotation is c1 to c2 and injuries are considered unstable due to the high cervical location and the lack of support all right so these injuries often result from high acceleration forces vertical compression is transmitted through the vertical bodies and its results from a direct blow to the crown or rapid deceleration from a fall through the feet legs and pelvis and a primary cervical spine injury is when the fragments of the bone become embedded in the cord",
        "Distraction Injury": "then there's the distraction injury so it's opposite of the compression it results when parts of the body are pulled in opposite directions most classic distraction injury is a hangman's fracture and mixed mechanisms with some sort of rotational flex and extension forces usually occur together with these injuries hyperextension is what it results in fractures and ligaments injuries of variable stability stable with the head and neck in flexion and unstable in extension due to the non-structural support",
        "Categories of Spinal Cord Injuries": "all right so categories of spinal cord injuries include the primary spinal cord injury that occurs at the moment of impact it could be penetrating trauma blunt trauma or spinal cord concussion spinal cord concussions are caused by fracture dislocations or direct trauma and then there's cord lacerations so this usually occurs when a projectile or bone enters the spinal canal",
        "Secondary Spinal Cord Injury": "then there's the secondary spinal cord injury it occurs when multiple factors create a progression of the primary spinal cord injury minimize further injury through stabilization natural alignment and spinal immobilization and then there's the effects of the spinal cord injury so that spinal cord compression it can it can result from an outsider internal forces on the spinal cord and both cervical spinal cord injuries either are complete or incomplete and a complete spinal cord injury is a complete disruption of all the tracks of the spinal cord it's a permanent loss of all chord mediated functions and then there's incomplete spinal cord injuries and that's uh some degree of the chord mediation function is retained",
        "Anterior Cord Syndrome": "anterior cord syndrome is a result of displacements of bony fragments into the interior portion of the spinal cord it's often due to flexation injuries or fractures then you have central cord",
        "Central Cord Syndrome": "syndrome this is hyperextension injuries to the cervical area present with hemorrhage or edema central cord syndrome often occurs in conjunction with tears to the anterior longitudinal ligament posterior cord syndrome and this is associated with extension injuries relatively rare syndrome and it produces dysfunction of the dorsal columns okay so next we're going to talk about",
        "Neurogenic Shock": "neurogenic shock it results from the temporary loss of the autonomic function at the level of the injury hemodynamic and systemic effects include hypotension hypovolemia and sensation to sudden position and changes and decreased stroke volume and cardiac output bradycardia and hypothermia an absence of swelling also there could be loss of bladder control priapism or some type of hypoactive bowels so the evolution of spinal care first you want to immobilize this is one of the most common procedures used in emergency medical services preventative",
        "Preventative Immobilization": "immobilization of all trauma patients became routine in the 1989 paper toted the benefits of immobilization so evaluation for each patient indications for immobilizations and benefits and risk of immobilization so potential negative consequences of using cervical collars and backboards the debate continues determine what tools are necessary for proper patient care per your protocol there's studies and providers can use certain criteria to identify patients who do not need to be immobilized patients who may not need to be immobilized include ambulatory patients or patients with penetrating trauma but no neurologic deficit also patients with a complete cord rd damage or spinal cord they they might need not need to be immobilized so complications are associated with immobilizing patients with penetrating trauma and they include it takes time and there could be delays and it takes multiple people and also immobilization can complicate and thereby delay airway management and other procedures within the primary survey so potential negatives of using a backboard you could have hyperextension of the cervical spine and it can result in a neurologic deficit patients immobilize for prolonged periods of time often develop pain in the occipit or sacral or lumbar lumbar areas there's other complications are ulcers and pressure sores or increased risk of aspiration respiratory compromise and rays in icp due to improperly fitted cervical collars",
        "Applications for Current Paramedic Practice": "so applications for current paramedic practice views on spinal immobilization may be based on historical approaches to treatment opinion and interpretation of data always follow your local protocols when providing any treatment and this also applies to mobilization so there are three common approaches to",
        "Common Approaches to Immobilization": "immobilization you could immobilize all trauma patients due to mechanism when patients with an identified mechanism are evaluated for the presence of a spinal cord injury and either fully mobilized or not and patients with a mechanism are evaluated for the presence of a spinal cord injury based on selective criteria so limiting the progression of secondary spinal cord injuries a major goal of pre-hospital management so treatment perform the primary survey including the abcde a foreman treatment plan and perform appropriate treatments as described earlier during the disability phase perform a neurologic exam and complete assessment of the spinal cord for deformity crepitus step offs and point tenderness place a cervical collar on if indicated and immobilize the patient to the backboard scoop stretcher or air mattress the goal should be to spend no more than 10 minutes on scene use a slur approach",
        "Treatment of Spinal Cord Injury": "to treatment of spinal cord injury for patients who have spinal cord injury with no life threats and do not ignore life threats to the abcs by focusing on immobilization and packaging of course",
        "Best Practices to Spinal Splinting": "okay so some best practices to spinal splinting is to remember that when splinting the spine should be considered one long bone there are a few caveats about traditional methods of spinal",
        "Spinal Immobilization": "immobilization so there is no optimal device for spinal immobilization you could use a vacuum mattress or pad behind the occipit adult patients require about half an inch to two inches of padding behind the occiput to maintain that neutral position because of the large occipit when you have the pediatric patient they require padding under the torso to maintain the normal position to avoid hyperflexation blanket rules between the legs and along sides of the body fill voids clot tape is a ineffective at mobilizing the head and body a rigid collar and a rigid cervical immobilization vice provide the best immobilization of the head head shoulders and pelvis should be immobilized because they are the weight centers of the body and are subject to the most movement axial movements provide better spinal alignment than do lateral movements",
        "Manual Stabilization": "manual stabilization so apply during the primary assessment or primary survey grasp the head firmly between your hands maintain manual stabilization from the patient's front rear or side and use neutral positioning to allow the most space for the cervical cord do not move the patient's head if the patient has any muscle spasms in the neck or increased pain move with movement or numbness and tingling and when you put on the collar so a cervical collar is intended to eliminate the axle load of the head by reducing flexation extension of the neck it does not prevent the patient from turning his or her head okay so maintain that stabilization even when you have the collar in place until the patient is fully immobilized so when they're supine the patient can be immobilized by securing him or her to the long backboard provide the greatest possible stabilization while immobilizing the patient okay and then place a blanket rolls on the side of the patient between the legs that could help fill those voids",
        "Straps To Secure the Patient to the Backboard": "if you're using individual straps to secure the patient to the backboard you must use at least five straps okay so one strap is going to be over each shoulder cross them in the center of the sternum at the x each strap to the side of the backboard opposite of the shoulder across several inches below the iliac crest is the next and then bring one strap over the top of the other crest cross these two straps at the pelvis and secure them near opposite sides of the hip and then you can secure the legs with the straight straps over the thighs and lower legs ensure that the head and torso and pelvis move as a unit with the teammates controlling the movement of the body patients found in the prone position or on their side should be log rolled into the supine position to be immobilized when it comes to seated patients the indications of spinal injury with the severity of associated injuries will dictate your approach to the seated patient if any of the following criteria are met lower the patient directly onto the backboard using a rapid extrication technique so if your patient's in danger or if you have to gain access to them immediately or if the patient has life-threatening injuries place the cervical collar and manually stabilize the entire spine seated patients may have no indication for spinal injury but if the patient is in cardiac arrest chest compressions take priority of course and then you're going to do that rapid extrication all right in the absence of a local protocol that directs you otherwise refer to skill drill 34-3 to mobilize the seated patient",
        "Rapid Extrication": "when it comes to rapid extrication rapid extrication is a process of manually stabilizing and moving the patient from a sitting position into an immobilization device without the use of a vest type device so use the rapid extrication when the vehicle is unsafe or the scene is unsafe or the patient cannot be properly assessed or the patient needs immediate intervention or immediate transport or the patient blocks your asset access to another serious injured patient do not use the rapid extrication technique if the injuries are not urgent and follow the extrication requires a rapid extrication requires a team of three experienced providers okay so these figures show the rapid",
        "Rapid Extrication Technique": "extrication technique packaging and removing an injured patient from water so when the patient has sustained a spine injury in a diving accident and the spinal mobilization must be initiated before the patient is removed from the water assume all spinal injuries if there's a it's a diving injury or boating injury or watercraft or fall from height if respiratory rest is suspected ventilation can be done while still in",
        "Cardiac Arrest": "the water cardiac arrest you need to quickly evaluate that mechanism in case of cardiac arrest when the spine injury is not obvious immediately remove the patient from the water and begin cpr if there is an indication of spine injury you want to place the patient prone place your arms across the head and back continue to support the head and neck open the airway and begin ventilation and secure the head and trunk to a backboard remove the patient from the water on the backboard remove wet clothes and cover the patient with a blanket and consider using an advanced airway device if needed and place the patient on a cardiac monitor if the treat dysrhythmias these figures show the process of stabilizing a spinal injury in the water when a patient wears helmets so helmets can inhibit full exposure of the patient hindering efforts of the respiratory management and stabilization the removal of helmet can result in spinal motion so only providers who are familiar with the",
        "Remove the Helmet": "procedure should attempt to remove the helmet alright so stabilize the helmet by placing your hands on either side of it with your fingers on the patient's lower jaw your partner should open the face shield and assess the airway and breathing once the strap has been unfastened your partner should place one hand on the patient's lower jaw and behind the head and gently slip the helmet partially off the patient's head stopping halfway then your partner then slides his or her hand from the back of the helmet to the occipit remove the helmet and provide manual inline stabilization and apply the rigid collar you may need to add padding under the shoulders to or the head to prevent flexation of the neck so this figure shows the steps we're just talking about to remove the helmet okay so",
        "Pharmacotherapy of the Spinal Cord Injury": "pharmacotherapy of the spinal cord injury short acting reversible sedatives are commonly recommended for acute agitated patients pain management may be necessary and corticosteroids were historically used in acute phase of a spinal cord injury but many recent protocols avoid their use",
        "Complications of the Spinal Cord Injury": "so complications of the spinal cord injury are a cause of high mortality and morbidity there are the provincial for aspiration and respiratory rest especially with high cervical injuries loss of intercostal muscle impairs coughing and deep breathing and deep vein thrombosis and pulmonary emblem emboli are late complications",
        "Autonomic Dysflexia": "autonomic dysflexia so it's also called",
        "Autonomic Hyperflexia": "autonomic hyperflexia and is a late complication it's potentially life-threatening most commonly occurs with injuries above t4 to t6 results in parasympathetic stimulation so a massive uninhibited cardiovascular response occurs systolic blood pressures of greater than 200 in diastolic of greater than 130 and then vagal compensation so it causes bradycardia and vasodilation of the peripheral and vascular vessels above the level of the lesion so common causes are skin lesions or constrictive clothing or shop sharp objects compressing so pre-hospital treatment you want to focus on supporting the vital systems and it may cause a reduction in blood pressure with vasodilators",
        "Non-Traumatic Spinal Conditions": "so then non-traumatic spinal conditions so back pain is common presentation for patients who call ems susceptibility to injury or degenerative disease may occur during due to weight and upright posture bears on the lumbar spine so also spinal tumors can also cause pain your assessment should cause should include the abcs and sample history evaluation of pain levels a typical finding is that pain diminishes with decreased movement so any patient with a suspected non-traumatic spinal disorder should undergo a neurologic and function examination before movement degenerative disc disease is common in patients older than 50 over time the disc will lose weight and some of the shock absorbing effect so disc herniation may occur in patients with pre-existing disc degeneration definitive diagnosis may require multiple modalities of x-rays and pre-hospital management is directed at decreasing pain or discomfort",
        "Spinal Stenosis": "then there's spinal stenosis and that's a narrowing of the spinal canal that can occur at single or multiple levels this causes compression of exiting nerve roots so pain radiates from the back to the legs and arms and place the patient in a comfortable position if transport is required and then you have injury prevention of",
        "Injury Prevention": "course prevention of the head and spine trauma includes safety measures that can decrease risk of injury driving safety and always wearing seat belts and motorcycles and all-terrain vehicles should not be ridden by two persons on the same vehicle so adhering to posted safety alerts for example those regarding safe diving at swimming pools okay so that concludes a chapter 34 head and spine trauma lecture thank you for joining us today"
    },
    {
        "Introduction": "hello and welcome to the emergency care in the streets chapter 33 face and neck trauma lecture",
        "National EMS Education Standard Competencies": "as a paramedic you will commonly encounter patients with injuries to the face and neck violent encounters and motor vehicle crashes are common causes of facial and neck trauma face trauma ranges in severity from a broken nose to penetration of great vessels in the neck this chapter provides a detailed review of the anatomy and physiology of the face and neck it also discusses injuries to the face and neck including their respective signs and symptoms and appropriate pre-hospital care okay so let's get started",
        "Introduction Continued": "you will commonly encounter patients with injuries to the face and neck the face and neck are frequently subjected to traumatic forces the face and neck are usually not covered with clothing and protective equipment like other parts of the body these injuries can be some of the most graphic you will see be careful not to lose focus solely on these injuries at the risk of missing other life threats",
        "The Facial Bones": "okay so let's talk about the anatomy and physiology of the facial bones you have 14 facial bones and they form the structure of the face could see these 14 bones on the photo the face is highly vascular this can result in significant hemorrhage in the setting of soft tissue injuries the orbits are formed by seven thin bones they help reduce the weight of the head they're vulnerable in nature a blowout fracture can occur if enough force is applied okay so next we're going to talk about",
        "The Ear": "the eye and first the globe or eyeball is susceptible to a variety of injuries including foreign objects impalements and burns movement is controlled by extraocular muscles which are controlled by several cranial nerves ocular motor nerve is the third cranial nerve it innervates the muscles that cause motion of the eyeballs and upper eyelids it carries parasympathetic nerve fibers that cause constriction of the pupil and accommodation of the lens the optic nerve does not control movement but provides the sense of vision when assessing for injury of the eye evaluate the sclera the cornea the conjunctiva the iris and the pupil this figure shows the parts of the eye okay moving on we're going to move next to the ear it's divided into three anatomic parts you have the external or the outer ear it consists of the pina and the external auditory canal then you have the middle ear it consists of the tympanic membrane malnus incus and staples the inner ear consists of semi circular canals the oval window the vestibular nerve the cochlear nerve the vestibule and round window and then the auditory tubule and the figure shows parts of the ear okay so paramedics are usually going to be providing treatment to injuries involving the external air injuries to the middle ear they may be visible but are difficult to treat in the field injuries to the inner ear may be come with complaints of vertigo and they generally cannot be treated in the pre-hospital setting either",
        "The Teeth": "moving on we'll move to the teeth in the mouth next so the adult mouth normally contains 32 permanent teeth when subjected to enough force the teeth can be dislodged during a traumatic insult to the face loose teeth will obstruct the airway and can be life-threatening paramedics should be familiar with the location of the different types of teeth and their components including the crown the cusp the pulp and the dentin okay so",
        "The Anterior Region of the Neck": "let's move on to the neck and first we're going to talk about the anterior region of the neck and the principal structures include the thyroid and the cricoid cartilage trachea and numerous muscles and nerves also you have major blood vessels in this area and they are the internal and external carotid arteries in the internal and external jugular veins vertebral arteries run laterally to the cervical vertebrae in the posterior part of the neck they supply oxygenated blood directly to the brain and upper spinal cord injury to any of these major vessels can produce a cerebral hypoxia and infarct an air emboli or permanent neurologic impairment other key structures include the vagal nerve the thoracic duct the esophagus the thyroid and parathyroid glands lower cranial nerves brachial plexus soft tissue and fascia and various muscles this figure shows the veins of the neck",
        "Scene Size-Up": "okay so let's get into the patient assessment of the injuries to this area first you start with the scene size up and assess and address any hazards assess for the potential for violence ensure standard precautions have been taken before you approach the scene and determine the number of patients consider whether you need additional or specialized resources and evaluate the mechanism of injury or moi and maintain a high index of suspicion for injury whenever a significant moi is present",
        "Primary Survey": "next we'll go into the primary survey after that scene size up and distracting soft tissue injury so do not take your focus off the abcs if there is a life-threatening bleeding or cardiac arrest the order would be c a b c d e general impressions so rapidly determine whether there is a life threat and check for responsiveness if a soft tissue injury to the head does not seem significant listen for obvious respiratory sounds as you approach the patient if you hear snoring respirations it's usually indicative of a positional problem gurgling respirations often indicate a need for suction and in a face or neck injury the oral pharynx may become occluded by the tongue secretions blood vomit foreign bodies or improperly inserted airways next we're going to do the a and the b so assess the airway as soon as you arrive at the patient's side if the patient has a potential neck or spine injury assign a crew member to perform manual stabilization while the airway is being assessed maintain immobilization until it is determined that spinal precautions are not indicated if precautions are indicated maintain until full spinal immobilization has been applied if the patient is unresponsive or has a significantly altered level of consciousness consider using an airway adjunct if blood vomit or any other substance is present in the airway immediately suction the airway if direct trauma is present it may severely compromise the airway assess the patient's breathing and adequacy employing corrective measures as needed this may include supplemental oxygen through an oxygen delivery device closely assess the signs for hypoxia if possible monitor the patient's oxygen saturation level maintaining it at least 94 percent or higher with supplemental oxygen as needed quickly assess for and treat any life-threatening injuries that may compromise ventilation ignoring those injuries until the secondary assessment can result in hypoxia and significantly increase the likelihood of mortality and morbidity now your c so your circulation palpate the pulse for its presence rate regularity and quality if no pulse is present take resuscitative measures assess skin ctc so color temp and condition paler ash and skin indicates inadequate perfusion and cool moist skin is an early indicator of shock control any visible significant bleeding and re-evaluate the patient's mental status and response to stimuli then is d your transport decision so patients with physiologic findings should be rapidly transported intervention that cannot be done and route should be delayed until after any immediate life threats have been addressed patients with isolated injuries are often better managed by carefully treating the injuries on scene okay so history taking",
        "History Taking": "was there a precipitating factor consider a medical reason that could lead to the trauma ask the patient and or family members and bystanders about the injuries such as was the patient wearing a seatbelt or was there airbag deployment how fast was the vehicle traveling how high is the location from which the patient fell or was there any loss of consciousness which type of weapon was used record the information on the patient care record and relay it to the during trade patient transfer if your patient is unresponsive and bystanders cannot provide information your only sources of information may be from the scene or medical alert jewelry",
        "Secondary Assessment": "when it comes to the secondary assessment in some cases you may not have time for the secondary assessment in other cases it may occur in route to the emergency department the secondary assessment of the head and neck is performed using the techniques of inspection and palpation and you need to observe for drainage from the ears or nose in the presence of paraorbital echomosis and that's raccoon eyes and the presence of retro ocular echomosis and that's battle signs symmetry of the face including eyes ears skull and the ability to smile deformity soft tissue injuries lumps or hemorrhage to the head and neck swelling occlusion and asymmetry narrowing to the ear openings lacerations or bite marks or missing teeth or evidence of dehydration additional assessment items include observe the position and condition of the uvula the posterior pharynx and the condition of the mouth oral mucosa teeth gums and tongue evaluate the patient's gaze noting if it is focus distance distant conjugate or disconjugate and ask about any visual disturbances observe the position and coloration of the eyes and look for every any evidence of trauma or infection also assess the pupils direct or indirect pupillary responses and extra extraocular movement assess the visual fields and for the presence of any visual field defects inspect the neck for jugular vein distension and note the presence of any enlarged lymph nodes in the neck palpate the face and neck asking the patient to report any pain or tenderness during your palpation and note the following findings any deformities or bony instability lumps or depressions of the skull deformities or evidence of soft tissue injury hidden in the hair or deformities or bony instability of the face deform deformities or bony instabilities of the mandible any enlargements or tenderness of the lymph nodes and tracheal deviation of the neck recall that in a setting of attention pneumo tracheal deviation if presence is a late finding",
        "Reassessment": "so next is the reassessment frequent reassessments should be made and route to the hospital every 15 minutes for a stable patient and every 5 minutes for serious obtain and evaluate the vital signs check interventions and monitor the patient's condition repeat the primary assessment and identify and treat the changes in the condition you may need to add additional dressings to the injury document should include the description of the mechanisms of injury the position in which you found the patient the location and description of the injuries and the accurate account of treatment if patients who have open injuries with severe external bleeding estimate and report the amount of blood loss",
        "Emergency Medical Care": "okay so let's talk about the emergency care of face and neck injuries and what you must focus on is the air protection airway issues are the most dangerous of results of injuries to the neck and face assess bandaging frequently so if blood soaks through bandages use additional methods to control the bleeding expose wounds control bleeding and be prepared to treat for shock evaluate all patients with major closed soft tissue injuries to see if there is a need for supplemental oxygen and maintain any oxygen saturation level of 94 or greater",
        "Pathophysiology of Face Injuries": "so pathophysiology soft tissue injuries open soft tissue injuries to the face may indicate the potential for more severe injuries massive soft tissue injuries to the face can compromise the airway maintain a high index of suspicion with closed soft tissue injuries to the face this suggests the potential for a more severe underlying injury impaled objects in the soft tissue or bones of the face present a high risk of airway compromise massive oropharyngeal bleeding can result in airway obstruction aspirations and ventilatory inadequacy blood is a gastric irritant ingestion may lead to vomiting and increasing the likelihood of aspiration maxo facial fractures so these commonly occur when the facial bones absorb the energy of a strong impact forces involved are also likely to produce traumatic brain injuries and cervical spine injuries when assessing protect the cervical spine monitor the patient's neurologic signs specifically their level of consciousness the first clue of a maxo facial fracture is usually echomosis and remember that's the black and blue mark on the face signs and symptoms include echomosis swelling pain on palpation crepitus or facial deformities or asymmetry instability of the facial bones impaired ocular movement and visual disturbances nasal fractures they're characterized by swelling tenderness and crepitus often complicated by an interior or posterior nose bleed that can compromise the airway mandible fractures and dislocations they typically result in a massive blunt force trauma to the lower third of the face may be fractured in more than one place so unstable on palpation should be suspected in patients with a history of blunt force trauma in the lower third of the face who present with some type of misalignment of the teeth numbness to the chin or inability to open the mouth other findings include swelling and echomosis over the fracture site or partially or completely evolves teeth eliciting tenderness by palpating specific locations on the mandible so point tenderness and pain on motion can identify injuries that patients might not report for a mandibular joint or tmj dislocations are most often the result of exaggerated yawning or widely opening the mouth the patient commonly feels a pop and then cannot close their mouth so maxillary fractures are most commonly associated with mechanisms that produce massive blunt facial trauma they produce massive facial swelling and instability of mid facial bones or an elongated appearance in the patient's face lefort fractures are classified in the three categories the lefort one fracture is a horizontal fracture of the maxilla it separates the hard palate and inferior maxilla from the rest of the skull the lefort ii fracture it's a fracture in the shape of a pyramid it involves the nasal bone and inferior maxilla and then the lefort3 fracture that's a fracture of the mid facial bones all of them it separates the mid face from the cranium look for cerebral spinal fluid leaking from the patient's nose this may indicate an open skull fracture orbital fractures so an orbital blowout fracture involves the bones of the orbital floor typically a mechanism of injury involves a fist dashboard or baseball striking the globe of the eye and surrounding soft tissues the patient may report double vision the patient may also lose sensation above the eyebrow or over the cheek massive nasal discharge and possibly csf impaired vision or paralysis of upward gaze treatment of an isolated orbital fracture is primarily supportive if the globe has been ruptured place a rigid eye shield over the affected eye and bandage both eyes okay so the cheekbone fractures cheekbone fractures commonly result in blunt trauma signs and symptoms include a flattened appearance on the injured side of the patient's face or loss of sensation over the cheek nose and upper lip their associated injuries include orbital fractures and echomosis and this table shows a summary of the maxo facial fractures",
        "Assessment of Face Injuries": "so assessment it is not important to distinguish among the various maxo facial fractures in the pre-hospital setting assessment is primary clinical you will observe with sight and touch instead of diagnostic equipment pay attention to swelling and deformity instability and blood loss evaluate the cranial nerve functioning so visually inspect the oral feral necks for signs of posterior echomosis signs include frank blood trickling down the back of the throat after a simple anterior echomosis has been controlled so alert the emergency department to the situation",
        "Management of Face Injuries": "and management management begins with protecting the cervical spine open the airway with the jaw thrust maneuver while maintaining manual stabilization of the head in the neutral position inspect the mouth for objects that could obstruct the airway and remove them suction the oropharynx as needed and insert an airway adjunct as needed unless absolutely necessary insertion of a nasal pharyngeal airway should not be performed in any patients with suspected nasal fractures csf or blood leaking from the nose or evidence of mid-face trauma unless it's absolutely necessary assess the patient's breathing and intervene appropriately if the patient is breathing adequately administer oxygen as needed to maintain oxygen saturation level of 94 or greater patients who are breathing inadequately should receive bag valve mass ventilation with a hundred percent oxygenation maintain oxygen saturation at greater than 94 okay so you might need to perform an endotracheal tube inhibition of patients with facial trauma this is because it protects the airway from aspiration it also ensures adequate oxygenation and ventilation you have to maintain inline cervical spinal mobilization restriction during this et tube innovation if et tube innovation is extremely difficult or impossible there may need be a need for surgical or needle cricoid thai thiarotomy foreign bodies in the throat create the potential for airway obstruction and aspiration so it's paramount to keep the patient calm and positioned so that if the object becomes dislodged gravity will allow it to fall out transport the patient in a position of comfort so treatment of facial lacerations and avulsions you treat them the same as you would any other soft tissue injury you want to control the bleeding with direct pressure and apply sterile dressings leave impaled objects in the face unless they pose a threat to the airway when removing an object from the cheek carefully remove it from the side that it is entered on and pack the inside of the cheek with sterile glass apply counter pressure with a dressing and bandage secured over the wound if profuse bleeding continues position the patient on his or her side to facilitate drainage of secretions from the mouth and suction the airway as needed for severe oropharyngeal bleeding with inadequate ventilation do the following you want to suction the airway for 15 seconds then provide ventilatory assistance for two minutes continue alternating until the air is cleared of blood and secured episodes is most effectively controlled by applying direct pressure to the nares the patient is responsive and mobilization is not indicated instruct the patient to sit up and lean forward as you pinch the nares together in unresponsive patients they should be positioned on their side if the unresponsive patient is immobilized on the backboard consider a drug assisted innovation carefully assess for signs of hemorrhagic shock cold compresses may help reduce the swelling and alleviate the pain of maxillofacial fractures do not apply to the eyeball if you suspect injury following an orbital fracture because it may increase increase interocular pressure and it may stimulate the ocular cardiac reflex okay so let's go into the",
        "Pathophysiology of Eye Injuries": "pathophysiology of eye injuries lacerations foreign bodies and impaled objects so lacerations of the eyelids require repair so it compression of the globe can interfere with blood supply and result in loss of vision and squeeze of the vitreous humor iris lens and retina out of the eye can cause irreparable damage foreign objects lying on the surface of the eye can produce severe irritation the conjunctiva becomes inflamed and red and that's conjunctivitis the eye produces tears in an attempt to flush the object an irritation of the cornea causes intense pain irritation is often further aggravated by bright light and most objects are easily flushed out but rest rust and metal cannot be removed by flushing and require removal by a physician so blunt eye injuries they range from injuries from swelling to echomosis to rupture of the globe hyphenia is bleeding into the anterior chamber of the eye that obscures vision visualization of the hyphenia you could do this by shining a pen light from an angle through the anterior chamber a patient with hyphenia will report photophobia pain blurred vision and drowsiness and if a patient has an altered level of consciousness suspect and treat for head injury retinal detachment is the separation of the inner layers of the retina it's a painless condition produces flashing lights specks or floaters in the field of vision it requires urgent medical attention central retinal artery artery occlusion it causes ischemia and necrosis of the retinal retina if blood flow is not restored quickly it can also cause permanent vision loss patients will complain of sudden painless vision loss of vision are commonly in the early 60s and are more likely to be male than female okay next we're going to talk about burns of the eye chemical burns require immediate emergency care chemical burns are usually caused by acid or alkali solutions the patient usually has a loss of vision and shows evidence of facial skin burns an acid burn generally causes immediate epithelial damage to the cornea alkalis can pass into the interior chamber of the eye rapidly exposing the iris ciliary body lens and other structures to further damage flush the eye with water or sterile saline solution if not available use any clean water for this purpose thermal burns occur when a patient is burned in the face by a fire eyes usually close rapidly but the eyelids remain exposed and are frequently burned infrared rays eclipse light and laser beams can cause significant damage to sensory cells superficial burns of the eye can result from ultraviolet rays these burns may not be painful initially but may become so three to five hours later severe conjunctivitis usually develops along with redness and swelling photophobia sensation of foreign objects in the eye and excessive tear production",
        "Assessment of Eye Injuries": "okay so let's talk about your assessment note the mechanism of injury ensure a patent airway inadequate breathing control any extraordinary external bleeding and if appropriate perform a rapid body exam when obtaining the history ask how and when did the injury happen when did the symptoms begin what symptoms is the patient experiencing were both eyes affected does the patient take any medications for his or her eyes and does the patient have any diseases or conditions of the eye symptoms that indicate serious ocular injury include vision loss that does not improve when the patient blinks double vision or severe eye pain or a foreign body sensation treatment for specific eye injuries begins with a thorough exam to determine the extent and nature of the damage during the physical exam evaluate each of the ocular structures and functioning the orbital ring look for echomosis and swelling lacerations and tenderness the eyelids look for ecchamosis swelling and lacerations the corneas foreign bodies the conjunctiva you're going to look for redness plus inflammation and foreign bodies the globes look for redness abnormal pigmentation and lacerations the pupils you're going to look at the size shape equality and reaction to light eye movements in all directions paralysis of gaze or discoordination between the two eyes and visual acuity patients ability to read a newspaper or a handheld visual acuity chart eye injuries are usually not life-threatening but should be evaluated by a physician or an ophthalmologist",
        "Management of Eye Injuries": "okay so management with lacerations and blunt trauma pre-hospital care of injuries to the eyelids include bleeding control and gentle packing of the eye patients should be transported to the hospital and bleeding can usually be controlled by gentle manual pressure examine the eye by inverting the upper and lower eyelids to look for the source of corneal abrasion looking for any foreign body in the eye supportive care in the pre-hospital setting may include irrigation which may help remove the object most injuries to the globe are best treated in the emergency department when treating penetrating injuries to the eye never put pressure on or manipulate the injured globe if part of the globe is exposed gently apply a moist sterile dressing to prevent drying cover the injured eye with a protective metal shield or cup or sterile dressing and apply soft dressings to both eyes to provide and provide prompt transport if you have bleeding or rupture of the globe is suspected take spinal motion restriction precautions if the globe is displaced out of the socket do not attempt to manipulate it or reposition it when it comes to foreign bodies and impaled objects so carefully evaluate the entire eye using a light you might be able to remove the object if it is on the surface of the lid with a moist sterile cotton tipped applicator when a foreign body is impaled in the globe do not remove it just stabilize the object and promptly transport the patient with burns of the eyes they can be caused by ultraviolet light and are treated by covering the eye with sterile moist pad and an eye shield apply cool compresses lightly over the eye if the patient is in extreme distress placing the patient in a supine position during transport with chemical burns they can rapidly lead to blindness immediately irrigate with sterile water or saline solution if only one eye is affected avoid getting the other one contaminated irrigate for at least five minutes if burn was caused by alkali or a strong acid irrigate continuously for 20 minutes this figure shows the direct method of irrigating eyes continue irrigation and route to the hospital control any contaminated runoff and local protocol will direct you to specialized treatments for burns to the eyes",
        "Pathophysiology of Ear Injuries": "okay so next we're going to talk about some ear injuries and they're soft tissue injuries so lacerations avulsions and contusions to the external ear can occur following blunt or penetrating trauma the pinna has a poor blood supply so it tends to heal poorly healing is often complicated by infection so when we talk about foreign bodies in the ear they're the most common in pediatric population assessment should determine the nature of the object and urgency of treatment so limited to visual clues such as bleeding or redness inflammation or symptoms associated with affection serious symptoms or discomfort as well as inserted objects that may cause harm or damage if untreated must be considered an emergency okay so a ruptured eardrum that's a perforation of the tympanic membrane and it can result from direct blows or foreign bodies or pressure related injuries such as blast injuries or diving related injuries signs and symptoms of a perforated tympanic membrane include loss of hearing or blood drainage from the ear the typanic membrane typically heals spontaneously ensure you have airway patency and breathing adequately when you're doing your assessment if mechanism of injury suggests a potential for spinal injury apply full spinal motion restriction precautions if manual directs pressure does not control bleeding place a soft padded dressing between the ear and the scalp apply a roller bandage to secure the dressing in place and apply an ice pack to reduce swelling and pain if the pena is partially evolved reline the ear into position and gently bandage it with padding that has been slightly moistened with normal saline if it has completely been evolved attempt to retrieve the evolved part for re-implantation at the hospital wrap it in a saline moistened gauze and place it in a plastic bag place the bag on ice if a chemical ice pack is used shield the evolves part with several gauze pads if blood or csf drainage is noted apply loose dressing over the ear do not remove any impilled object from the ear just stabilize it and cover the ear to prevent gross movement and minimize the risk of contamination perform a careful assessment to detect and rule out more serious injuries before proceeding with specific care",
        "Pathophysiology of Oral and Dental Injuries": "okay so the pathophysiology and assessment management of oral and dental injuries they're commonly associated with trauma to the face primary risk associated with them of course is airway compromise and the pathophysiology so soft tissue injuries lacerations and avulsions are associated with risk of hemorrhaging and subsequent airway compromise an assessment of any patient with facial trauma should include a careful examination of the mouth fractured or evolved teeth and lacerations of the tongue may cause profuse bleeding into the upper airway a responsive patient with severe oral bleeding is often unable to speak unless he or she is leaning forward patients may swallow blood from lacerations inside the mouth objects impaled in or through soft tissues in the mouth can result in profuse bleeding and this is a risk of vomiting and aspiration when it comes to dental injuries they may be associated with mechanisms that cause severe maxo facial trauma or they may occur in isolation always assess the patient's mouth following a facial injury teeth fragments can become an airway obstruction in an unconscious patient with missing teeth that cannot be located assume that the teeth are in the airway direct visualization with a laryngoscope may be necessary to ensure they are not in the airway or to remove them if they are",
        "Assessment and Management of Oral and Dental Injuries": "ensuring airway patency and adequacy breathing is priority so suction as needed remove fractured tooth fragments apply spinal mobilization restriction precautions as dictated and if profuse oral bleeding is present and the patient cannot control his or her airway pharmacologically assisted innovation may be necessary impaled objects in the soft tissue should be stabilized in place unless they interfere with breathing or ability to manage the airway medical control may ask you to re-implant an evolved tooth so place the tooth in its socket hold it in place to have the patient bite down if pre-hospital implantation is not possible follow the guidelines established by the american association of endodontist and american dental association if the patient is unstable airway management spinal precautions and rapid transport are the most important with the dental problems addressed at a later time",
        "Pathophysiology of Injuries to the Anterior Part of the Neck": "so let's talk about the pathophysiology management and assessment of injuries to the anterior part of the neck classification of neck injuries by dividing the neck into zones so injuries to zone one can extend into the chest and may not be easily recognized on physical examination injuries in zone 2 are the most common usually the most obvious and have lower mortality rate injuries in zone three often are difficult for surgeons to assess and repair because many of the structures under the base of the skull okay when you talk about pathophysiology of injuries to this interior part of the neck soft tissue injuries you have to be alert for cervical spine injury and airway compromise common mechanisms of blunt trauma include motor vehicle crashes or direct trauma or hangings blind trauma often results in swelling and edema and injury to very structures such as the trachea or larynx or epiglottis and or esophagus and also injuries to the spine so be prepared to initiate aggressive management of blood injuries common mechanisms of penetrating trauma include gunshot wounds stabbings or impaled objects primary threats from penetrating trauma are massive hemorrhaging and airway compromise also air embolize are associated with open neck injuries this is because exposed jugular veins may suck air into the vessel and occlude blood flow so you want to seal with an occlusive dressing immediately and avoid constriction of the vessels and structures of the neck also be alert for swelling and expanding hematomas unpaled objects can present several life-threatening problems injury to major blood vessels with massive hemorrhage damage to the larynx trachea and esophagus and injury to the cervical spine do not remove impaled objects stabilize and protect them from movement the only exception is if the object is obstructing the airway or impeding the ability to manage the airway emergency cricothyrotomy may be necessary so injuries to the larynx trachea and esophagus these injuries may result if the structures of the anterior part of the neck are crushed against the cervical spine or if they are penetrated by an object injuries may not be obvious and can be easily overlooked significant injuries to the larynx or trachea pose an immediate risk of airway compromise esophageal perforation can result in mediastinus that is inflammation of the mediastinum and it's often due to leakage of gastric contents into the thoracic cavity maxo facial fractures can make bag valve mass ventilation difficult in et innovation may also be challenging if not impossible so if techniques to secure the airway are unsuccessful or impossible a surgical or needle crycothromy may be necessary assessment",
        "Assessment of Injuries to the Anterior Part of the Neck": "common signs associated with injuries to the anterior part of the neck include bruising redness to the underlying skin palpable tenderness note the mechanism of injury and maintain a high index of suspicion this is because the patient may have experienced trauma to multiple body systems if the patient is unresponsive manually stabilize the patient's head in a neutral inline position and open the airway with the jaw thrust maneuver suction as needed then assess the patient's breathing if adequate apply a non-rebreather mask at 15 liters and if adequate assist with a bag valve vas ventilation at a hundred percent",
        "Management of Injuries to the Anterior Part of the Neck": "always treat the injuries that will be the most rapidly fatal perform a rapid exam to detect and treat other injuries to control bleeding from the open neck wound immediately cover the womb with an occlusive dressing you can also use a ecg electrodes they can be a fast and effective way to seal a small hole or holes apply direct pressure over the occlusive dressing with a bulky dressing secure a pressure dressing by wrapping roller gauze loosely around the neck and then firmly through the opposite axilla monitor the patient's pulse for reflex bradycardia if signs and symptoms of shock are present administer oxygen keep the patient warm establish vascular access within at least an 18 gauge and infused an isotonic crystalloid solution as needed patients with serious laryal trauma may require a surgical or percutaneous airway consult your local protocols et tube innovation may be hazardous because of the tip of the et tube may pass through the defect in the laryngeal or tracheal wall signs and symptoms of this complication include increased swelling of the neck and worsening subcutaneous emphysema during ventilation in an open tracheal wound a cuffed et2 may be able to pass through the wound to establish a patent airway use caution the trachea may be perforated both anteriorly and posteriorly and use multiple techniques for confirming the direct et2 placement okay so pathophysiology of the spine trauma the neck is subject to injury that may not result in bony injury and a sprain is stretching or tearing of ligaments and the strain is stretching or tearing of muscle or tendon the muscles respond by contracting in an attempt to support the neck maintain a high index of suspicion for cervical involvement cervical precautions should always be taken",
        "Assessment of Spine Trauma": "when you do assessment transport patients to the emergency department for x-rays conduct a visual inspection for signs of soft tissue injury and if the patient is symptomatic with pain maintain spinal immobilization if the mechanism of injury dictates spinal clearance protocol and your examination produces pain or resistance stop the exam maintain spinal stabilization and transport the patient for further evaluation in the ed",
        "Management of Spine Trauma": "patients reporting neck pain after injury should be evaluated in the emergency department address any airway ventilation and oxygen considerations and prevent further injury with motion restrictions if your examination reveals no obvious mechanism of injury consider treatment as you would for any other muscle muscular strain this includes rest ice and evaluation a soft collar may support the head and strain muscles and patients reporting neck pain should still be evaluated for injuries",
        "Injury Prevention": "so prevention many improvements and advancements have been made in providing protection to the face and neck to prevent injury during activities in which there's a high risk of being hit um the following are used so helmets face shields mouth guards and safety glasses advances in motor vehicle safety include better occupant safety restraints and airbags and improvements to headrests okay so this concludes chapter 33 face and neck trauma lecture we hope that you've enjoyed it if you have go ahead and push the like button and subscribe to our channel"
    },
    {
        "National EMS Education Standard Competencies": "and welcome to Emergency Care in the streets chapter 29 trauma systems and mechanisms of injury basic concepts of the mechanism and biomechanics of trauma will help you analyze and manage your patients injuries analyzing a trauma scene is a vital skill because at the scene you are the eyes and ears of the emergency department Physicians the paramedic written patient history is the only source for Physicians and surgeons to understand the events and mechanisms that led to your trauma patients Chief complaint your information is critical as a foundation to visualize and search for injuries that may not be apparent on physical exam so let's get started trauma is the",
        "Introduction": "primary cause of death and disability in patients and people between the ages of 1 and 44 years old basic concepts of mechanics and biomechanics of trauma will help you analyze and manage your patients injuries analyzing a trauma scene is vital you are the eyes and ears as we said earlier of the emergency department Physicians and your patient history is the only source for for these Physicians so let's talk about trauma energy and kinetics trauma is an acute physiologic and structural change that occurs when an external source of energy affects the body Beyond its ability to sustain and dis dissipated there are different forms of energy and they produce different forms of trauma so we're going to talk about these forms of energy first one we're going to talk about is mechanical and that is um energy from motion so kinetic energy for example two moving vehicles iding or there's also energy stored in an object and that's that potential energy for example a brick sitting on a building ledge then you have chemical energy and that's energy released as a result of a chemical reaction for example an explosion or an acid there's thermal energy and that's energy transferred from sources that are hotter than the body for example a flame hot water or steam you have electrical energy and that's a for example electrocution or lightning strike and a barometric energy and that's a sudden radical change in pressure for example scuba diving or flying biomechanics is the study of the physiology and mechanics of living organisms using tools of mechanical engineering it can be used to help analyze the mechanisms of and results of trauma and kinetics is a study of the relation a ship among speed Mass direction of force and physical injury caused by these factors and it can be used to help predict injury patterns okay so next we're going to talk about",
        "Factors Affecting Types of Injury": "some factors affecting types of injuries the kind of injury sustained will be determined by the ability of the patient's body to disperse the energy delivered external factors that determine types of energy include source and energy so it's the size and that's known as the mass of the object delivering the force the velocity that's how fast the object was moving acceleration or deceleration and that's how fast the object speeds up or slows down and the body area affected by the application of the force the duration or direction are also important factors the larger the area of force dissipation the more pressure is reduced to the specific spot in the body so blood trauma spreading of impact without breaking the skin is difficult to to diagnose it's often um little external damage and it's rapidly applied amounts of energy are less tolerated than the same amount of energy delivered over a long period of time the position of the trauma victim at the time of the event is another external Factor seat belt use has reduced lethal injuries by keeping victims in safer positions the impact resistance of body parts has been has a bearing on types of tissue disruption as well often determined by what's inside the patient's organs so organs that have gas inside will shatter energy more than liquid or solid boundaries and are easily compressed so lungs and gastrointestinal tracts liquid containing organs are less compressible so Vas ular system liver spleen and muscle understanding the effects of forces will help to assess the mechanism of injury you can help predict most likely the type of injury paramedics should have a high index of Suspicion for injuries that may be undetected be quick and deliberate with your primary survey and",
        "Kinetics": "interventions okay so let's talk about everybody's favorite kinetics first we're going to talk about velocity that's the distance an object travels per unit of time and then there's the acceleration that's the rate of change of velocity an object is subject to next we're going to talk about gravity and that's the downward acceleration and parted to any object moving towards Earth during each second of a fall the velocity or speed of the falling object increases by 9.8 mass per second squared kinetic energy is associated with an object in motion it reflects the relationship between the weight of the object and the velocity at which it's traveling and velocity has a much greater effect than Mass okay the kinetic energy of a car in motion that stops suddenly must be transferred or applied to another object modern cars have crumple crumple zones to maximize the amount of energy absorbed by deformation before the pasture is involved okay other factors that will affect the amount of energy dissipation in a crash vehicle include the vehicle's Angle an angle of an object uh front Impact versus side impact or how the patient hits the inside of the automobile and differences in sizes of the two vehicles or restraint status and protective gear of the occupants each vehicle involves contributes kinetic energy to the crash law of conservation of energy so energy can neither be created nor Desto destroyed it can only be changed um and so energy dissipation is the process of kinetic energy is transferred into a form of mechanical en en energy if a car stops slowly kinetic energy is converted to thermal energy if a car crashes kinetic energy is also converted into mechanical energy so mechanical energy is further dissipated in the form of an injury protective devices can manipulate the way in which the energy is dissipated stuff like seat belts and airbags or helmets Newton's first law of motion is a body at rest will remain at rest unless acted on it by an outside force and similar a body in motion tends to stay in motion unless acted on it by an outside force Newton's second law of motion is the force of an object can exert in the product of its mass times its acceleration so it's written um as on the slide Force equals mass time acceleration the higher an object's mass and acceleration the higher the force needed to make a change of course so d acceleration is a slowing down or slowing to a stop acceleration and deceleration can be measured in numbers of g4ce one gForce is normal acceleration due to gravity two or three g4ce is two or three times the force associated with gravity the human limit to deceleration is 30 G force in a head-on crash transfer energy is represented as the sum of both Vehicles",
        "Multisystem Trauma": "speed okay so multi-stem trauma describes injuries that involve several body systems the body has a much harder time dealing with multiple injuries that involve several major body areas generally caused by events that affect the entire body often blunt both blunt and penetrating trauma occurs if you suspect that multi body systems are infected assess the pat patients entire body and prioritize the treatment of the injuries and transport patients without",
        "Blunt Trauma": "delay first we're going to talk about blunt trauma blunt trauma refers to injuries in which the tissues are not penetrated by external objects so commonly occurs in motor vehicle accidents or Med pedestrian hit by a vehicle motorcycle crashes or Falls from Heights sports injuries or blasts when no shrapnel is",
        "Motor Vehicle Crashes": "involved first we're going to talk about motor vehicle crashes so there are five phases of trauma tied to the effects of progressive deceleration when a vehicle collides with another object phase one is deceleration of the vehicle the vehicle strikes another object and is brought to an abrupt stop the vehicle motion continues until kinetic energy is dissipated phase two is deceleration of of the occupant and it starts during the sudden breaking and continues during the impact of the crash the results in deceleration compression and sheer trauma depend on the mass of the occupant the mechanisms the protective mechanisms body parts involved in the points of impact next we're going to talk about phase three it's deceleration of the internal organs the body supporting structures and movable organs continue the forward momentum until stopped by anatomic restraints it may result in tears and shearing injuries phase four is those secondary collisions that's the occupant hit by moving objects in the vehicle such as loose packages or objects or other passengers and phase five is additional impacts received by the vehicle so a vehicle may be hit by a second vehicle or a vehicle deflected into another vehicle or tree or",
        "Impact Patterns": "object so when you talk about trauma we need to talk about impact patterns how dented and deform the vehicle looks is an indication of the forces involved and the degree of deceleration sustained by the patient dense and deformity on the inside of the vehicle will show you the point of impact on the patient head injury or belt marks indicate what parts of the body may have been involved and tire skid marks at the scene indicate whether significant en energy was dissipated by breaking before the crash front or head-on impacts the front end of the car distorts as it dis dissipates the kinetic energy and decelerates its Forward Motion passengers decelerate at the same rate as the vehicle forces applied to the driver will defer based on the car design and the materials abrupt acceleration injuries are produced by a sudden stop of the body's Forward Motion it can induce shearing EV voling or rupturing of organs injuries are often visible during exam the head is vulnerable in deceleration injuries it can cause the brain to strike the inside of the skull causing bleeding bruising and tearing injuries the aorta is the most common site of a deceleration injury in the chest often torn away from its points of fixation to the body can result in the loss of total blood volume and immediate death also internal organs that continue their motion after motion of the body stops can result in tearing and cheering injuries commonly the liver kidneys large intestines pancreas and spleen crush and compression injuries are as a result of forces applied to the body by other things external to the body so often dashboards or windshields or the floor or heavy objects falling on the body so assume spinal cord injuries and severe brain injuries compression injuries of the head may result in a skull fracture compression injuries of the chest May produce fractured ribs and compression of the heart may cause dymas and direct injury to the heart muscle and compression of the legs can result in acute respiratory distress syndromes unrestrained occupants usually follow one of two trajectories Down and Under pathway and this is the occupant slides under the steering column or Dash the knees hit the dashboard energy of deceleration is transmitted up the femurs to the pelvis and upper torso continues forward until the impacts the vehicle you want to look for fractures or disloc ation of the knees hip and pelvic fractures hip dislocation spinal injuries rib fractures or pulmonary and cardiovascular injuries after the Down and Under pathway it's the up and over pathway that's the lead the lead point is the head the head impacts the windshield roof mirror or dashboard it can include significant head and cervical spine trauma and also injection as possible if the windshield does not stop the body a dangerous lung injury may occur if your patient's reflectivity takes a deep breath just before impact and lower leg fractures could be present next we're going to talk about after the front or head-on impacts is the lateral or side impacts impart energy to the near side it occupant directly to the goes to the pelvis and chest seat belt offer little protection because they are designed to limit forward hinging injuries as the passenger compartment deforms the pastor's head can strike the impacting vehicle or object and of course there could be direct trauma or tension uh developed on the far side the shoulder frequently rotates forward exposing the chest and ribs to injury the passenger's body is pushed in One Direction when the head moves towards the impacting object passenger stret travel travel in opposite directions often colliding with each other and death is usually the result of associated torso and head injuries next we're going to talk about rear impact and they have the most survivors if the driver and passengers are properly restrained whip whip blast injury from the sudden forward acceleration force caused the body to move forward but not the head and energy is important to the front vehicle and then there's rotational or cordal panel impacts and so it occurs when a lateral crash is off center the point where the vehicle's greatest loss of speed occurs is where the greatest damage to the occupant will occur and occupants tend to receive frontal and lateral injuries three point seat belts are effective in preventing injuries in angled crashes of up to 45\u00b0 and then there's the rollovers this has the greatest potential for lethal energy patients may be ejected and patients may be struck hard against the interior of the vehicle ejection increases the chance of death by eight",
        "Restrained Versus Unrestrained Occupants": "times unrestrained versus restrained occupants so seat belts stop the motion of any automobile occupant who is traveling at the same speed of the vehicle it limits the contact of the occupants with the interior of the vehicle and it prevents ejection specific injuries associated with seat belts use include cervical fractures and neck sprains most serious injuries occur because the patient did not use the seat belt correctly airbags have reportedly reduced desk in frontal crashes by about 30% front airbags will will not activate in a side impact crash or impacts in the front corner panel it can also result in secondary injuries from direct contact or from the chemicals used to inflate it and small children can be severely injured or killed if the airbags inflate while they're in the front",
        "Motorcycle Crashes": "seat okay next we're going to talk about motorcycle crashes so any structural protection afforded to the victim is DED from the protective devices worn by the rider so Helmet or leather or abrasion resistant clothing and boots and the helmet of course protects against impact forces Just To The Head And it transmits impact into the cervical spine when assessing the scene attention should be given to the deformity of the motorcycle and the side of most damage distance of skin in the road deformity of stationary objects or other objects and the extent in location of the deformity of the helmet there are four types of motorcycle impact there's the head-on angular impact then you also have the ejection or laying the bike down so let's talk a little bit about those next when it comes to head-on impact the motorcycle strikes another object and stops its Forward Motion the rider continues forward until it's stopped by an outside force for motorcycles with low riding seat the gas tank can act as a wedge on the pelvis and it can result in an anterior posterior compression injuries or an open pelvic fracture angular impact is when the motorcycle strikes an object or another object or vehicle at an angle the rider sustains direct crushing injuries to the lower extremity between the object and the Motorcycle it could result in severe open or commun lower extremity fractures or traumatic amputations of those lower extremities next is the ejection so Rider who will travel at a high rate of speed until stopped by a stationary object or another vehicle or by contact with the road and usually severe abrasions um down um the bones can occur and then the last one is laying the bike down that's a technique used to separate the rider from the body of the motorcycle and the object to be hit it's developed by motorcycle racers racers as a means of controlling a crash the motorcycle is turned flat and tip sideways at a 90 degre uh direction of travel so that one leg is dropped to the ground it slows um the rider faster than the motorcycle allowing the rider to be separated from the motorcycle the helmet should be removed carefully if the airway management techniques cannot be performed with the helmet in place and also if the helmet does not fit snugly to the head you need to remove the motorcycle helmet the helmet should be cut if it cannot be removed without introducing further deform deformation to the neck so um bicycles and off-road vehicles such as four-wheelers or snowmobiles are capable of producing injuries similar to those of",
        "Pedestrian Injuries": "motorcycles Okay so we've talked about car crashes we've talked about motorcycle crashes now we're going to get into The Pedestrian injuries almost 85% of pedestrians are strucked by a vehicles's front end adult injuries are generally lateral and posterior they tend to turn to the side or away from an object and children Face Forward into the oncoming vehicle there are three prominent mechanisms of injury so you have the first impact the second impact and the third impact the first impact is the when the auto strikes an adult body and its bumpers second is when the adult is thrown on the hood or the grill and the third is when the body strikes the ground or some other object it has been um subjected to by the sudden acceleration of the colliding vehicle pedestrian patterns of pedestrian injury are different from dults okay so the wadell Triad refers to a pattern of injuries in children and people of short stature so this is when the bumper hits the pelvis and femur instead of the knees and tibas the chest and abdomen hit the grill or low on the hood of the car the head strikes the vehicle and then the ground and this could result in skull and facial fractures facial abrasions and closed head",
        "Falls from Heights": "injuries okay so after pedestrian injuries we're going to talk about Falls from Heights next and remember the fall produces an acceleration downward the severity of the injuries affected um are affected by the height and the position okay so the height will determine the velocity of the Fall the height plus stopping distance predicts the magnitude of the deceleration forces okay so the position will determine the type of injury sustained and the likelihood of survivability children tend to fall head first and this results in head injuries and adults usually try to land on their feet okay and so there is a Don Juan syndrome or lovers leap and it's a group of potential injuries from a vertical fall to a standing position so you have foot and lower extremity fractures hip then vertebrae ex um compression and then fractures of the forearm and wrist okay so the area the larger the area of contact the greater the dissipation of force then the surface that the person lands on so the degree to which the surface can deform under the force of the body can help dissipate forces of sudden deceleration if the surface does not conform the body will and then there's physical conditions so pre-existing medical conditions could influence injury sustained osteoporosis is the most notable it predisposes to fractures even with minimal forces so in hematologic conditions are prone to rupture spleen and",
        "Penetrating Trauma": "fall all right so we did Falls from Heights now we're going to talk about penetrating injuries so penetrating trauma involves a distribution of the skin and underlying tissues in a small focused area usually caused by Firearms knives and other devices used as a means to cause intentional or accidental harm it's classified as low medium or high velocity and so we'll talk about low velocity first and the the injury is caused by sharp edges of the object moving through the body when it comes to medium and high velocity such as a bullet the path of the object might not be easily to predict because uh it might flat now tumble or even Ricochet within the body in the United States the most common sources of penetrating injuries are firearms in 2013 33,6 36 people died by gunfire in the United",
        "Stab Wounds": "States stab wounds so the severity depends on the region involved the depth of the penetration the blade length and the angle of penetration it may also involve a cutting or hacking type Force such as machete wounds neck wounds can involve critical anatomic structures and deep neck wounds can result in spinal cord involvement or cervical fractures and the pattern of the Stab Wound closely relates to the mechanisms involved and should be documented in",
        "Gunshot Wounds": "detail gunshot wound so the severity of the gunshot wound depends on several factors the type of the firearm the velocity of the projectile the physical design and the size of the projectile and the distance of the victim from the muzzle of the firearm type of tissue that is struck we have shotguns and they fire round pellets the shot density can uh induce destructive injuries at a very close range then there's rifles they fire single projectiles at high velocities um they have Groove veril Imports a spine to the projectile for accuracy and then there's handguns so revolvers hold 5 to 10 Rounds the pistol holds about 17 rounds and uh rifled barrel Imports spin to the bullet but accuracy is limited and um ammunition is generally less powerful than rifles and Fires at a lower velocity when you talk about ballistics that's the study of non-powered objects in flight so most often associated with rifle or handgun bullet travel when the bullet leaves the barrel of the gun gravity begins to pull it towards the Earth trajectory is the curve of the bullet's path related to how fast it falls to the Earth after leaving the barrel air creates drag on the bullet as it moves through the air so automatic weapons use the back pressure from firing a bullet to eject the spent cartridge the same mechanism loads the next round into the chamber to be fired fully automatic weapons fire each round as soon as it's loaded into the chamber as long as the trigger is held down and um it's rarely found outside the military the trigger must be pulled and released each time a new round is loaded for a semi-automatic weapon to be fired the most important factor for seriousness of gunshot wound is the type of tissue through which the projectile passes entrance wounds are characterized by the effects of the initial contact in implosion so skin and tissues are pushed in cut and abided at close range tattoo marks from Powder Burns can occur and at closer range Burns can occur from the musle blast deformation and tissue destruction is based on a combination of factors so the density the compressibility the missile velocity and the missile fragmentation okay and continuing with gunshot wounds the projectile crushes the tissue during penetration it creates a permanent cavity and it may be a straight simple or a regular pattern so the pathway expansion that's the tissue displacement that occurs as a result of the low displacement Sonic pressures that travel at the speed of sound and tissue bowel muscle and lungs are relatively elastic resulting in fewer permanent effects of temporary C CIT cavitation liver spleen and brain are relatively inelastic resulting in a more permanent effects of that cavity missile fragmentation that's the projectile when it sends off fragments to create their own separate paths through those tissues Exit Wounds occur when the projectile has sufficient energy that is not entirely dissipated along its trajectory through the body the size depends on the energy dissipated and the degree of cavitation at the point of exit usually has irregular edges and it may be larger than entry wounds so shotgun wounds are the result of tissue impact by numeral numerous projectiles the greater the distance of the muzzle from the target the more dispersion the projectiles will have and wounding potential depends on the powder charge the size and number of pellets and the dispersion of the pellets okay",
        "Blast Injuries": "after talking about gunshot wounds next we're going to talk about blast injuries and there's four different types or categories of blast injuries and we're going to um discuss those next the first one is the primary blast injury and this is damaged to the body it's caused by the pressure wave generated by the explosion organs generally are that are affected are the lungs and eard drums and other compressible organs close proximity to the origin of the pressure wave carries a high risk of injury and death then there's the secondary blast injuries it results from being struck by flying debris objects can travel great distances and can be propelled at tremendous speeds up to nearly 3,000 mph for conventional military explosives a blast wind occurs as a shock wave applies Force to air molecules and flying debris can cause blunt and penetrating injuries and then you have the third type that's the tertiary blast injury it occurs when a person is hurled by the force or the explosion a ground shock is a physical displacement of the body when the body impacts the ground it results in injuries are numerous and may be blunt Andor penetrating you have the fourth type of injury it's the miscellaneous blast injury and it results from miscellaneous events that occur during the explosion such as burns from the hot gases or fire started by the blast perhaps respiratory injury from inhaling toxic gases also Crush injury from the collapse of the buildings and there's risks for entrapment then you have the fifth blast injury and that is caused by the biologic chemical or radioactive contaminants that have been added to a traditional explosive device It's associated with dirty bombs and there's an increased concern to the threat of use by terrorist organizations the figure on this slide shows the mechanisms of those blast injuries you could see the the five different types",
        "Physics of an Explosion": "all right so let's talk about the physics of explosion when a substance is detonated it is converted into large volumes of gas Under Pressure propellants are explosives designed to release energy relatively slowly compared to high explosives so components of blast shock wave is the blast front that's the Leading Edge of the explosion pressure blast wave then you have the positive w wave pulse that's a phase of the explosion in which there is a front higher than the atmospheric pressure you also have shock waves and those are high explosive blast waves and then you have negative wave pulse and that's a phase in which the pressure is less than atmospheric it occurs as the air displaced by the pressure wave pulse returns to fill the space the speed duration and pressure of the shock wave are affected by the size of the explosiv charge the nature surrounding the medium the distance and the Pres the presence or absence of reflecting surfaces an explosion is more damaging in closed spaces and a blast pressure causes destruction at interference between tissue and different densities or of different densities and the interference between tissue and trapped air tissues at risk are air containing",
        "Tissues at Risk": "or organs and are they're more susceptible to pressure changes such as the middle ear the heart lungs major blood vessels and the GI tract Junctions between tissues of different densities and exposed tissues are prone as well the ear is the most sensitive to blast injuries the tanic membrane will rupture at pressures of 5 to 7 PSI above atmospheric pressure patients May complain of ringing in their ears pain in their ears loss of hearing or visible blood in the ear canal primary pulmonary blast injuries occur as concussions and hemorrhages so patients may have tightness in their chest Topia or other signs of respiratory distress or subcutaneous empyema and that is uh indicates an underlying numo or also pulmonary edema if there are any reason to suspect lung injury in a blast victim admit Min oxygen avoid giving oxygen though under pressure and IV fluids may be poorly tolerated in patients with a lung injury arterial air emilii occurs on avolar disruption with subsequent air embolism into pulmonary vasculature one of the most concerning pulmonary blast injuries even small air bubbles can enter a coronary artery and cause a myocardial injury solid organs are relatively protected from shock wave injury but may be injured by secondary missiles or when the body's hurled neurologic injuries and head trauma are the most common causes of death from blast injuries extremity injuries including traumatic amputations are common and blast injuries are more common today due to increased use of explosives as a tool for urban terrorism and methamphetamine lab explosions assessment and management of blast injury so when you are at the scene of an explosion expect significant trauma and multiple victims if the explosion was intentional examine for an area for a secondary device and assess the scene for hazards exposed electrical wiring or structural instability shop or sharp objects and assess breath sounds frequently examine the patient rapidly for the presence of Decap btls and establish basic pulsox value and reassess frequently an absent of avert signs of abdominal injury should not lead you to conclude that the injury is not present dizziness due to ear injuries may lead to vomiting and can interfere with the patient Airway p patency and",
        "Scene Size-Up": "protection okay so let's talk about the assessments all right so General assessment for this for trauma managing a trauma scene involves more consideration of external factors than the typical scene with a medical patient your observations are critical to H Hospital staff very few trauma injuries can be truly stabilized on scene so start with your scene size up of course attention to personal protective equipment is required gloves and the likelihood of bleeding is higher in trauma patients also eyewear or helmets or heavy coats or boots could be needed and anticipate possible scene hazards while in route and call for assistance before you need them assess your environment clearly um environment carefully and as you approach your patient consider whether you need additional medical",
        "Primary Survey": "resources the primary survey so of course fir that General pression patients who look very ill or present with obvious bleeding injuries often have serious injuries do not make major patient decisions based strictly on your first impression keep the mechanism of injury in mind as you approach and evaluate the patient using avpo if the patient does not require CPR and does not have life-threatening hemorrhages next assessed Airway status okay so Airway and breathing if your patient is unresponsive ask your partner to open the airway using the jaw thrust maneuver observe for obvious oral and facial trauma that may contribute to an airway obstruction if necessary remove foreign objects and ction out blood or vomit if a patient's unresponsive consider an oral or nasal Fingal Airway if you suspect blockage due to a foreign object apply the appropriate manual Airway clearing technique if the airway is clear assess the patient's breathing absence of breathing will require the bag valve mask and consider of a more advanced Airway adjunct but if the patient is breathing note the right Rhythm and quality of the respirations and and the patients ability to speak next you're going to note the skin color and observe chest wall movement with respirations assess the thorax and neck you're looking for trachea deviation tension numo neck and chest crep crepitation broken ribs fractured sternums and other problems that may inhibit breathing determine how to best support your patients breathing most trauma patients will benefit from application of oxygen even in in the Pres um absence of dipsia and then after the A's and the B's you're on to the C's so check both radial and crowded pulses simultaneously to estimate blood pressure and pulse note rate and quality of pulse and skin condition can also be a good indicator for circulation quickly scan for significant external bleeding assess for disability you want to evaluate the glass galcom score note pupil size equal in reactivity to light evaluate pulse motor and sensation in all extremities and expose the patient for exam scan quickly for life threats and manage life threats as you find them and then is your D so AB c d we're going to do that transport decision patients that should be categorized for immediate transport include those with altered mental status Airway and breathing problems multi-stem trauma and the um compromised circulation if a patient needs immediate transport continue your assessment and route to the trauma center on scene time should be limited to 10 minutes or less you want to re that's referred to the Platinum 10 and after the first 60 Minutes in shock the body has increased difficulty compensating and that's referred to as the golden hour the first 60",
        "History Taking": "minutes after your primary is your history and the history is sample remember in op CST sample is the history of the patient so the medical history should be obtain as soon as possible in case the patient level of Consciousness deteriorates if the patient's unresponsive you need to gather the info from the bystanders or family members if you can important information is remember allergies medications past medical history patients last oral intake or events leading up to the situation",
        "Secondary Assessment": "your secondary assessment for trauma patients are classified into two major groups those with an isolated injury and this is going to allow you to immediately focus on that problem or those with multi-stem trauma so you must first find all the various problems then prioritize the severity and think about how each injury or condition relates to the others and then of course is the vital signs and that's when you want to obtain a full set of initial or Baseline Vital Signs and you should include the assessments of pulse respiratory or respirations and um blood pressures and other measurements that should be considered are pulsox bgl cardiac monitoring and automatic blood pressure monitoring with your physical exams most multi-stem traumatic injury patients should have a thorough physical exam prior to transport should be done in a systemic manner you're going to work from the head to the toes and you're going to go down and look for any Decap btls now dcap btls stands for deformities contusions abrasions penetrations Burns tenderness lacerations and swelling when you start at the head you're going to start and check the nose mouth ears for bleeding re-examine the pupils for size equality and re reactivity to light check the for jvd and tracheal deviation press a finger down in the notch at the top of the sternum if the trachea is palpated in its position it's midline if it's to one side it's deviated consider applying a c collar when you and then continue your assessment move down to the chest you want to expect so and palpate the chest wall look for penetrating injuries and assess for bruising use your stethoscope to listen to breath and heart sounds palpate the abdomen across the upper and lower quadrants press the ilc crest down and squeeze them inward to determine pelvic stability and consider palpation of the pubic synthesis examine for signs of incontinence or bleeding from the grin area when you move down to the extremities you're going to palpate the legs from top to bottom palpate each leg separately and note the difference you have to um check both feet for distal pulses motion and sensation and then the back while the patient is on his or her side examine for back",
        "Reassessment": "injuries you're going to reassess the patient and route to the hospital and you want to perform another full body rapid scan repeat the primary survey and re-evaluate vital signs every 5 minutes for patients in serious conditions review the status of the interventions that you've performed and notify Hospital staff as quickly as possible next we're going to talk about the trauma score trauma scoring systems are often used to determine injury severity in health care profession there are several different systems trauma score is used to determine the likelihood of the patient survival calculated on a scale from 1 to 16 16 is the best score takes into account the glass caloma score the respiratory rate respiratory expansion and systolic blood pressure and cap refill and then there's the glass caloma score and that is an evaluation tool used to determine the level of Consciousness its scores are assigned for eye opening verbal response and motor response and it can be used to predict patient outcome as well it does not accurately predict survivability though in patients with head injuries in these instances the revised trauma score is used which leads",
        "Revised Trauma Score": "us to talking about the revised trauma score or RTS it is a score used to assess injury severity in patients with head trauma it's heavily weighted on um compensation for major head injury with multi-stem injury and major physiologic changes the data used to calculate the score is a glass Calcom score the systolic blood pressure and the respiratory rate and so all um also used to predict survival in patients with severe injuries so the highest revised trauma score is 12 and the lowest is a zero and you could see the table and the elements elements of the revised traumas score Cal okay so management of trauma so the",
        "Management of Trauma": "management of trauma requires an accurate assessment of the patient and the knowledge of the mechanics of injury during transport begin any necessary interventions most trauma patients will need to be treated for shock and that includes establishing IVs administering fluid boluses and transporting rapidly unresponsive trauma patients will most likely need an advanced Airway placed and most patients who are in Shock should include oxygen keep supine with extremity slightly elevated and transport rapidly to a Trauma Center you want to um also consider fluid resuscitation um if shock is caused by a large fluid shift and large quantities of fluid may be required if shock is caused by blood loss too much fluid can dilute the blood and raise blood pressure okay so consult with medical control begin fluid resuscitation at volumes that maintain a minimum blood pressure and this will still allow clots to form at sites of bleeding within the body several techniques can be used to treat multi-stem trauma multi-stem trauma patients cannot be stabilized in the field use a team approach to assess and transport your patient critical thinking is important when treating a patient with multi-stem trauma signs and symptoms may be related to different response mechanisms okay so let's talk about the",
        "Trauma Lethal Triad": "trauma lead lethal Triad next and um the the Triad consists of hypothermia poor blood clotting and acidosis and so even mildly hypothermic patients have a lower survival rate than normothermic patients and hypothermia um contributes to coagulopathy and that's poor blood clotting so any factor that interferes with blood clotting will cause greater blood loss and that of course results in poor profusion and ultimately death then the third uh side of that triangle it's uh acidos acidosis and it often occurs with excessive bleeding and treatment to compensate for it uh it contributes to um poor blood clotting and comp complicates treatment so management we're going to aggressively seek to control the bleeding to the best of our ability we have to keep patients warm and minimize the volume of acidotic IV fluids that we administer so the criteria for referral",
        "Criteria for Referral to a Trauma Center": "to a trauma center the American College of Surgeons committee on trauma and Centers for Disease Control and prevention published a field triage decision scheme so physiologic criteria if one of the following is present refer to the highest level trauma center a GCS score of less than 13 systolic blood pressure of less than 90 and a respiratory rate less than 10 or more than 29 or the need for ventilatory support support an automic criteria so if one or more of the following is present we need to transport to the highest level of Trauma Center a penetrating trauma to the head neck or torso and extremities proximal to the Elbow or wrist chest wall instability or deformity two or more proximal long bone fractures crushed the glove mangled or pulseless extremity amputation proximal to the wrist or ankle fracture or open or dis depressed skull fracture also paralysis mechanism criteria so if one or more of the following is present and depending on the mechanism of injury they want you to transport to the closest Trauma Center adults who fall more than 20 feet children Falls more than 10 feet or two to three times the height of the child and highrisk motor vehicle accidents so if there's intrusion into the p compartment ejection partial or complete from an automobile and vehicle Telemetry data consists with a high risk of injury pedestrian and bicyclist thrown or run over or an pedestrian injury with significant impact or a motorcycle crash at more than 20 M an hour also there are special considerations to go to the trauma facility if the patient's age is more than 55 systolic blood blood pressure is less than 110 in a person older than 65 children should be triaged to a pediatric compatible trauma center and patient uses anti-coagulants or has bleeding disorder or a patient who is pregnant more than 20 weeks gestation low impact mechanisms in older adults may result in severe injury and burns with other trauma it's also an EMS provider judgment the ACs coot publishes a list of criteria defining four separate levels of Trauma Centers there's one two three and four it is important to know which hospitals specialize in neurology Burns pediatric trauma Cardiac Care micro surgery or hyperbaric chamber therapy you want to give the trauma center early notice of the patient's arrival including the age sex mechanism of injury Vital Signs glass Calcom score whether the patients innovated sample history or significant",
        "Mode of Transport": "coorilos should be considered can the appropriate facility be reached within a reasonable time frame the extent of of the injuries and if it's in a congested area criteria for appropriate use of emergency air Medical Services include the extended period required to access or extricate a remote or trap patient that uh um the time frame to get the patient to the trauma center by ground um that it depletes it so distance to the trauma center is greater than 20 or 25 miles or the patient needs medical care and stabilization at an ADV advaned life support level and there are no ALS ground units available the traffic conditions also in the hospital availability make it unlikely that the patient will get a Trauma Center via ground in a good time frame and um there are multiple patients who will overwhelm s resources at the trauma center EMS systems require that the patient be brought to the nearest hospital for initial stabilization and evaluation and there is is a mass casualty incident you should always follow your local protocol when determining the type of transport and when making the transport decision also consider if the patient can be transported by ground within a reasonable time time will take for the aircraft to lift off and land and then the",
        "Research and Trauma Care": "terrain so research and Trauma care the military has done extensive research over the many years regarding trauma care civilian research shows that what works well in the military does not always work well in the civilian world for example the use of pneumatic anti-shock garments for patients with penetrating RS to the upper body was found to be harmful in the 1980s even though they were used for many years in Vietnam War recent military research has shown that the dangers long associated with trate use are not as serious as they once assumed and so there's great L increased tnic use in the control of extremity bleeding in the civilian population good research should drive the changes in prehospital management of trauma patients and only evidence-based um treatment should be adopted for widespread use okay well this concludes chapter 29 trauma systems and the mechanisms of injury lecture thank you for joining us this evening or to day whenever you're listening to this lecture and we hope you come back and join us for another lecture thank you"
    },
    {
        "Introduction to Face and Neck Injuries": "chapter 29 face and neck injuries traumatic forces often affect ffect the face and neck resulting in a variety of injuries common injuries in these areas include soft tissue damage and fractures to the underlying bones which can sometimes become life-threatening penetrating trauma to the neck has the potential to cause significant hemorrhage due to vascular injury open wounds in this region May introduce air into the circulatory system leading to the development of an air embolism which can further complicate the injury additionally such trauma May obstruct or significantly reduce cerebral blood flow resulting in neurological deficits or brain injury as advanced emergency medical technicians when managing a patient with face and neck injuries your primary objectives include preventing further trauma particularly to the cervical spine which is highly vulnerable in such situations situations additionally addressing and managing acute Airway issues is critical as face and neck injuries can compromise the airway finally controlling Hemorrhage is an important aspect of care as these injuries may lead to significant blood loss especially if major vessels are involved",
        "Anatomy of the Head and Neck": "the head is anatomically divided into two primary sections the cranium and the face the facial skeleton consists of six major bones including the nasal bone two maxill two zygomas and the mandible the mandible plays a key role in forming the jaw and Chin providing the structure and support for these facial features the motion for the mandible occurs at the temporo mandibular joint which is located anterior to the ear on both sides of the face Additionally the hyoid bone a semicircular structure is positioned just below the mandible in the superior region of the neck unlike other Bones the hyoid is not connected to other bones but is suspended by muscles and ligaments contributing to the mobility and function of the neck and lower jaw the interior region of the neck contains several vital structures including the thyroid cartilage cryo cartilage trachea and various muscles and nerves the thyroid cartilage forms a noticeable prominence at the center of the neck commonly referred to as the atom Apple which is the upper part of the linic located just below the thyroid cartilage is the CID cartilage a firm Ridge that supports the airway connecting these two cartilagenous structures is the cryo thyroid membrane which plays a role in maintaining the structural Integrity of the Linex lateral to these key structures including the vessels and nerves are the steroid mastoid muscles which are responsible for the neck movement and stability",
        "Anatomy of the Eye": "the eye is a globe-shaped structure approximately 2 cm in diameter and housed within a bony socket in the skull known as the orbit it's held in place by loose connective tissue in several muscles the oculomotor nerve inates these muscles also carrying parasympathetic nerve fibers that facilitate certain functions the optic nerve is responsible for transmitting visual information to the brain providing the sense of vision the orbit forms the base of the cranial cavity floor with the frontal loes of of the brain situated directly above it the eyeball maintains its shape due to the pressure from the fluid within its two Chambers the anterior chamber is filled with aquous humor while the posterior chamber contains Vitus humor the outer surface of the globe is covered by the Scara a tough protective layer that plays a role in maintaining the structural Integrity of the eye the inner surface of the eyelids and the exposed surface of the eye are covered by a transparent membrane known as the conjunctiva which is kept moist by fluid secreted from the lacrimal glands the opening of the center of the iris is called the pupil which regulates the amount of light entering the eye some individuals are born with pupils of unequal size a condition referred to as an escoria this this condition can be physiological and may not necessarily indicate an underlying pathology",
        "Anatomy of the Ear": "the ear is a complex organ that's responsible for Hearing and Balance it is anatomically divided into three main sections the external ear consists of the PA and the external auditory canal which direct sound waves toward the middle ear the middle ear contains three small bones the malus incus and stapes which work together to transmit sound vibrations from the eardrum to the inner ear the inner ear comprises a series of bony Chambers filled with fluid which are involved in both the auditory processing and maintaining equilibrium",
        "Airway Compromise from Upper Airway Injuries": "injuries to the upper Airway can result in partial or complete obstruction which is often caused by several factors direct trauma to the nose mouth linic or trachea may lead to Airway compromise dislodged teeth or dentures can further obstruct the airway if they become displaced during the injury soft tissue swelling following trauma may also narrow the airway impeding air flow additionally injuries to the brain or cervical spine can impact neurological control the airway while damage to the great vessels of the neck can cause significant Hemorrhage and exert pressure on the airway structures cervical spine injuries can also complicate Airway management due to the need for spinal immobilization and risk of further spinal damage",
        "Soft Tissue Injuries in Face and Neck": "soft tissue injuries to the face and neck are frequently encountered in trauma scenarios due to the area's vulnerability and extens Ive vascularity the rich blood supply in this region can result in more pronounced swelling and significant himage particularly in the case of penetrating injuries blunt trauma may lead to the formation of hematomas as blood accumulates beneath the skin the presence of these soft tissue injuries often indicates the potential for more serious underlying damage to critical structures including the airway vascular system in cervical spine when a patient presents with a closed soft tissue injury to the face or neck it's important to maintain a high index of Suspicion for more serious underlying injuries there is a significant risk of Airway compromise due to swelling or hematoma formation which can obstruct air flow additionally if blood from facial areas is swallowed it can act as a gastric irritant potentially leading to nausea and vomiting which further complicates Airway management and patient care",
        "Facial Fractures and Their Management": "facial features occur when the facial bones absorb the force from a strong impact the force required to fracture the maxilla is significant and often associated with closed head injuries and cervical spine trauma therefore it's important to protect the cervical spine and closely monitored neurological sign signs especially the patient's level of Consciousness common signs and symptoms of facial fractures include deep facial lacerations pain over the affected bone ecosis swelling tenderness upon palpation crepitus misalignment of the teeth visible facial deformes or asymmetry instability of the facial bones impaired ocular movement and visual disturbances immediate assessment and stabilization are necessary to prevent further complications especially in regard to Airway compromise and spinal injury",
        "Nasal Fractures": "nasal fractures are the most common type of facial fracture they are typically characterized by swelling tenderness and crepus over the nasal area deformity of the nose often presenting as a lateral displacement of the nasal bone is a frequent feature of such fractures these injuries are frequently Complicated by epit taxis which can occur from either the anterior or posterior regions of the nasal cavity proper assessment and control of bleeding along with the evaluation of any Associated injuries are necessary in the management of these fractures",
        "Mandibular Fractures": "mandibular fractures result from significant blunt force trauma to the lower third of the phase the most common sight of fracture is the angle of the jaw while multiple fractures typically involve the chin these injuries should be suspected in patients with a history of trauma to the lower face especially if they present with signs such as Dental malocclusion chin numbness and difficulty opening the mouth point tenderness and pain with motion can help identify these fractures even in cases where the patient may not report obvious symptoms",
        "Maxillary Fractures": "maxillary fractures are typically the result of mechanisms that produce severe blunt trauma to the face these fractures are categorized using the lefor classification which describes different patterns of maxillary fractures a lefor one fracture is the horizontal fracture of the maxilla which separates the hard pallet and the lower maxilla from the rest of the skull a lefor 2 fracture involves both the nasal bone and the inferior maxilla resulting in the separation of the nasal bone and the lower maxilla from the facial skull and the remainder of the cranial bones a lefor 3 fracture also known as cranofacial disjunction is the most severe involving a fracture of all the mid- facial bones which separates the entire mid face from the cranium these fractures are serious and often require prompt intervention to address Airway management bleeding and potential neurological compromise",
        "Orbital Fractures": "orbital fractures such as blowout fractures occur when the bones surrounding the eye are damag often as a result of blunt trauma common signs and symptoms of orbital fractures include double vision and a loss of sensation either above the eyebrow or over the cheek reduced sensation may occur in areas innervated by the infraorbital nerve additionally patients may experience massive nasal discharge impaired vision and paralysis of upward gaze which can indicate more extensive damage to the ocular structures or surrounding bones",
        "Zygomatic Fractures": "zygomatic fractures commonly result from blunt trauma such as that experienced in a motor vehicle collision in physical assaults the most notable signs and symptoms include a flattened appearance on the affected side of the face loss of sensation over the cheek nose and upper lip due to nerve involvement and paralysis of upward gaze these fractures are often associated with additional injuries such as orbital fractures ocular injuries and epita taxis",
        "Dental Injuries": "Dental injuries including fractured and evoled teeth are common and may occur as a result of severe maxillofacial trauma or an isolation it's essential to assess the patient's mouth following any facial injury as dislodged teeth or fragments can pose a significant risk of Airway obstruction if Dentures are well fitting they should be left in place to maintain normal oral structure and function in emergency medical care complete spinal immobilization is vital for any patient with suspected spinal injuries while maintaining spinal precautions it's crucial to ensure the airway remains open and administer high flow oxygen control any significant visible bleeding promtly if the patient exhibits signs of hypo profusion immediate management of shock is necessary including aggressive a fluid resuscitation patients in critical condition should be transported without delay deferring nonlifesaving treatments until they reach the hospital IV access should be established using one or two large boore catheters and in cases of hypo profusion administer 20 ml per kg boluses of an isotonic crystalloid solution to maintain radial pulses",
        "Managing Soft Tissue Injuries": "when assessing and managing soft tissue injuries the primary focus should be on protecting the airway Begin by evaluating the patients ABCs addressing any immediate life-threatening conditions standard precautions including personal protective equipment should always be taken if no life-threatening bleeding open and clear the airway and ensure it remains patent throughout care impatients with suspected cervical spine injury take appropriate precautions by using the jaw thrust maneuver to open the airway followed by suctioning the mouth as needed control any external bleeding using direct manual pressure to prevent further blood loss the goal is to manage immediate threats while maintaining spinal precautions and ensuring Airway patency when managing soft tissue injuries ensure that any exposed parts are covered with moist sterile dressings to prevent contamination and promote healing facial lacerations and avulsions should be treated in a similar fashion to other soft tissue injuries ensuring proper cleaning dressing and monitoring for infection additionally check for any bleeding inside the mouth as it can contribute to Airway compromise and may require immediate intervention to prevent aspiration or construction for a v skin that has been completely separated from the body wrap the tissue and a sterile dressing moistened with saline then place it in a plastic bag store the bag in a cool environment but never place the tissue directly on ice as this can damage the tissue ensure the bag is labeled with the patient's name and transported to the emergency department along with the patient if the skin is still partially attached gently position it as close to its normal anatomical alignment as possible to promote optimal healing and reduce the risk of further damage",
        "Eye Injuries and Their Management": "injuries to the eyes require prompt and proper emergency treatment to reduce pain and prevent permanent vision loss in a healthy uninjured eye the entire circle of the iris is visible with the pupils being round equal in size and re acting uniformly to light additionally both eyes should move together in coordination when tracking a moving object such as a finger after an injury however these normal functions may be disrupted leading to abnormal pupil reactions or changes in eye movement it's important to note that abnormal pupil responses can sometimes indicate a brain injury rather than a direct eye injury requiring further evaluation when assessing eye injuries it's important to identify specific abnormalities or conditions that may indicate the nature of the trauma foreign objects in the eye can cause conjunctivitis where the conjunctiva becomes red and inflamed accompanied by tear production as the eye attempts to flush out the irritant corneal or conjunctive irritation results in severe pain which is worsened by bright light making it difficult for the patient to keep their eyelids open irrigation with sterile saline is often effective in removing loose small particles from the eye if available a small bulb syringe nasal Airway or canula can be used to direct the saline into the affected eye always flush from the nose side outward to avoid pushing debris into the other eye sometimes foreign objects leave abrasions on the conjunctiva but gentle irrigation may not dislodge particles stuck to the cornea or lodged under the upper eyelid to inspect under the upper eyelid gently pull the lid upward and forward if a foreign object is visible try removing it using a moist sterile cotton tipped applicator however you should never attempt to remove the object adhere to the cornea as this could cause further damage when a f body is impelled in the eye it should not be removed by anyone other than a physician as improper removal could cause further damage the key priority is to stabilize the object and prepare the patient for transport the longer the foreign object is protruding from the eye the more important it is to stabilize it securely to do this bandage the object in place to prevent movement cover the affected eye with a moist sterile dressing and create a donut-shaped collar using roller Galls or small Galls pack to support the object without putting pressure on it it's important to banage both eyes with soft bulky dressings to prevent the injured eye from moving as movement in one eye will cause sympathetic movement in the other potentially worsening the injury any embedded foreign body in the eye must be urgently addressed by an opthalmologist to avoid permanent damage and ensure proper treatment",
        "Chemical and Thermal Burns to the Eye": "for burns to the eye immediate steps must be taken to stop the burn and prevent further damage chemical burns are commonly caused by exposure to acidic or alkaline Solutions the first step in managing chemical burns is to flush the affected eye with clean water or sterile saline for at least 5 minutes to dilute and remove the chemical agent if available use a bulb or irrigation syringe nasal canula or any device that allows control over the flow of water if such tools are unavailable gently pour water into the eye by positioning the patient's head under a running faucet when only one eye is affected take care to avoid contaminating the unaffected eye by directing the flow away from it after irrigating the affected eye for at least 5 minutes continue flushing from the inner corner of the eye toward the outer corner to prevent contamination of the unaffected eye if the burn was caused by an Alkali or strong acid extend the irrigation time to at least 20 minutes as these substances can cause deeper tissue damage once irrigation is complete apply a clean dry dressing to cover the eye and prepare the patient for transport if irrigation equipment is available in the ambulance the process should continue during transport to ensure ongoing decontamination and minimize further damage for thermal Burns affecting the eyes particularly Burns to the eyelids Specialized Care is required these patients should be transported promptly without delay both eyes should be covered with a sterile dressing moistened with sterile saline to protect the burn tissue additionally eye Shields may be applied over the dressing to provide further protection during transport",
        "Light Burns to the Eye": "light burns including those caused by infrared Rays Eclipse Light and Laser Burns can cause significant damage to the eyes retinal injuries from exposure to extremely bright light are typically painless but may result in permanent Vision impairment superficial eye burs may occur from ultraviolent Rays such as from an arc welding unit prolonged exposure to a sunlamp or reflected light from a bright snow covered area although initially painless these Burns may become painful 3 to 5 hours later severe conjunctivitis which is characterized by redness swelling and excessive tear production usually develops in response to these Burns to treat light burns cover each eye with a sterile moist pad and place an Eye shield over the dressing have the patient lie down during transport and protect them from further light exposure",
        "Lacerations to the Eye": "lacerations to the eye require extremely careful repair to restore both appearance and function in cases where the globe itself has been lacerated it's critical not to apply any pressure to the eye the following treatment guidelines should be observed never apply pressure or manipulate the injured eye in any way as this can cause further damage if part of the eyeball is exposed gently cover it with a moist sterile dressing to prevent the tissue from drying out cover the injured eye with a protective metal Eye shield cup or sterile dressing and minimize movement of the injured eye by covering up the uninjured eye as both eyes will move with accommodation if the eyeball is displaced from the socket do not attempt to manipulate or reposition it instead cover the eye and stabilize it with the moist sterile dressing to protect the exposed tissues as with other serious eye injuries cover both eyes to prevent further movement and injury to the affected eye position the patient in a Seine position to reduce the risk of fluid loss from the eye and help stabilize the patient for transport",
        "Blunt Trauma to the Eye": "blunt trauma to the eye can result in a range of injuries from a simple black eye to more serious conditions like a severely damaged Globe one common consequence of blunt trauma is hyphema which involves bleeding into the interior chamber of the eye obscuring all or part of the irus in such cases the eye should be covered to protect it from further injury and the patient should be transported for further care hyphema may also indicate the presence of a spinal injury requiring careful assessment and treatment to reduce intraocular pressure Elevate the head of the backboard to approximately a 40\u00b0 angle discourage the patient from performing activities that could increase intraocular pressure such as coughing an orbit fra fracture commonly known as a blowout fracture typically involves a fracture of the bones that form the floor of the eye socket and support the globe in cases of orbit fracture place the patient on a stretcher and ensure prompt transport to the emergency department for Specialized Care protect the injured eye using a metal shield and cover the other eye to minimize movement retinal detachment occurs when the inner layers of the retina separate from the underlying choid this condition is commonly seen in sports particularly in contact sports like boxing although painless retinal detachment can result in symptoms such as flashing lights specks or floaters in the field of vision and patients May report a cloud or Shadow over their Vision this is a medical emergency that requires urgent intervention to preserve the patient's vision and prevent permanent damage",
        "Eye Injuries Following Head Injury": "eye injuries following a head injury can indicate the possibility of more severe underlying trauma Key signs to watch for include one pupil being larger than the other disconjugate gaze and the eyes failing to follow your finger as instructed other indicators are bleeding under the conjunctiva which could obscure the Scara and protrusion or bulging of one eye for an unresponsive patient it's important to keep the eyelids closed to protect the eyes you can cover them with moist Galls or gently hold them closed using clear tape this prevents drying and further injury to the eyes during transport management of eye injuries resulting from blast trauma depends on the severity of the injury if if a foreign body is embedded in the globe do not attempt to remove it instead protect the injured eye using a clean cup or similar object to Shield the area follow local protocols if only one eye is injured if the patient has severe swelling or a hematoma on the eyelid avoid forcing the eyelid open to examine the eye as this could cause further damage",
        "Contact Lenses and Artificial Eyes": "when dealing with contact lenses and artificial eyes in a patient after an eye injury it's important to never attempt to remove a lens from an injured eye unless it is a chemical burn case where the contact lens must be removed immediately to prevent further damage to remove a hard contact lens use a small suction cup moistened with saline for soft lenses apply one to two drops of saline into the eye and gently pinch the lens between your gloved thumb and index finger to lift it off of the eye surface place the contact lens in a sterile saline filled container to protect it from damage and ensure that emergency department staff are informed if the patient is wearing contact lenses if you suspect that the patient has an artificial eye you can confirm this by noting if the eye does not respond to light does not move in coordination with the opposite eye or appears different in structure",
        "Nose Bleeds and Nasal Injuries": "nose bleeds are a common occurrence often caused by dry air or digital trauma they are classified as either anterior or posterior depending on the location of the bleeding anterior nose bleeds typically originate from the septum and tend to bleed slowly usually resolving on their own without significant intervention however posterior no bleeds are more severe and can result in blood draining into the throat which requires more attention trauma to the face and skull such as a basil or skull fracture can destabilize the posterior wall of the nasal cavity blunt force injuries to the nose caused by mechanisms such as a fist or a dashboard during a motor vehicle collision can also be associated with fractures facial soft tissue injures inuries head injuries or cervical spine injuries when assessing nasal injuries it's important to examine all nasal structures patients with severe nasal trauma may also have Associated cervical spine injuries additionally cerebral spinal fluid May leak from the nose or ears following a skull-based fracture which is a critical sign of significant trauma this figure shows the two chambers of the nose divided by the septum each chamber is composed of layers of bone called turbinates above the nose are the frontal sinuses and on either side the orbit of the eye epita taxis following facial trauma is most effectively managed by applying Direct pressure to the NS which can help control the bleeding for abrasions and lacerations control the bleeding by applying a sterile dressing to the affected area in addition it's important to assess the patient for signs of hemorrhagic shock particularly if there is significant blood loss if shock is suspected administer crystalloid fluid boluses intravenously to help stabilize the patient's circulatory status monitoring the patient closely for further signs of deterioration is essential as early recognition and treatment can prevent complications",
        "Ear Injuries": "injuries to the ear can result in sensory impairment and in some cases permanent disfigurement though they typically do not bleed extensively if local pressure is insufficient to control bleeding apply a roller dressing start by placing a small padded dressing in between the back of the ear and the scalp bandaging the ear directly against the scalp can cause significant discomfort if there is blood or cerebral spinal fluid drainage apply loose dressing over the ear to protect the area without applying pressure for partially evoled ears carefully realign the pen into its normal position and gently bandage it with sufficient padding slightly moistened with normal saline if a part of the ear has been fully evoled make an effort to retrieve it for potential reimplantation treat the Evol part as you would any other amputation by wrapping it in sterile gauze moistened with saline placing it in a plastic bag and storing it in a cool environment never place the amputated part directly on ice do not attempt to remove an impelled object from the ear as this should be handled by a medical professional all foreign bodies in the ear should be removed by a physic in the emergency department do not attempt to manipulate or move the foreign object as improper handling can cause further damage signs and symptoms of a perforated tanic membrane include hearing loss and blood drainage from the ear known as hemorrhagic atoria",
        "Facial Fractures and Airway Obstruction": "in cases where a patient has sustained a direct blow to the mouth or nose it's important to maintain a high index of Suspicion for a potential facial fracture additional Clues indicating the facial fracture include bleeding in the mouth difficulty or inability to swallow or speak the presence of absent or loose teeth and the detection of loose or movable bone fragments during assessment facial fractures while not typically considered acute emergencies can become life-threatening if there is significant bleeding these injuries usually indicate blunt force trauma and the bleeding May pose a risk of Airway obstruction if blood clots become lodged in the upper Airway additionally fractures around the face and mouth may result in deformity and loose bone fragments that can further complicate the injury plastic surgeons can often repair damage to the face and mouth if treated within 7 to 10 days in such cases it's important to remove and preserve AAL teeth or loose bone fragments as they may be replanted any loose Dentures or dental bridges should be removed to prevent Airway obstruction swelling is another potential cause for Airway obstruction which can become extreme within the first 24 hours following an injury",
        "Oral and Dental Injuries": "oral and dental injuries can result from blunt mechanisms such as motor vehicle collisions or direct blows to the mouth or chin as well as from penetrating mechanisms including gunshot wounds lacerations and punctures the primary concern with these injuries is the risk of Airway compromise due to or aerenal bleeding occlusion from a displaced Dental Appliance or as spiration of a vge of fractured teeth to manage these injuries suction the Ora faex is needed and remove any fractured tooth fragments to maintain a clear Airway apply spinal immobilization based on the mechanism of injury to protect the cervical spine then control any bleeding by direct pressure and in cases a severe or aerenal bleeding with inadequate ventilation suction the airway for 15s seconds followed by providing ventilatory assistance in cases where an object is impaled in the face leave it in place and stabilize it appropriately unless it poses an immediate threat to the airway if the object risks obstructing the airway removing it might be necessary but this should be done cautiously for injuries inside the mouth such as a lacerated cheek pack the inside of the cheek with sterile Galls to control bleeding applying counter pressure by securing a bandage and dressing over the outside of the wound to minimize swelling and promote clotting when managing an Evol tooth always handle the tooth by the crown avoiding contact with the root to prevent damage it's critical to ensure the tooth is not dry out so place it in the suitable storage medium such as saline or milk and inform the receiving facility about the Evol tooth so they can prepare a potential reimplantation",
        "Neck Injuries": "injuries to the neck are serious and should be treated as life-threatening blunt trauma to the neck especially crushing injuries can severely affect the Linx or trachea the cartilage structures of the upper Airway and Linx much fractured do not return to their normal positions which can lead to several complications potential consequences include loss of voice difficulty swallowing severe and potentially fatal Airway obstruction and the leakage of air to the soft tissues of the neck subcutaneous empyema which is a crackling sensation caused by air in the soft tissues of the neck is a critical sign that requires immediate action if you detect this when palpating the neck prioritize maintaining the airway and transport the patient immediately as complete Airway obstructions can occur rapidly if managing the airway does become difficult paramedic support may be necessary any injury to the throat may also result in a cervical spinal injury necessitating spinalization to prevent further damage to the spine",
        "Penetrating Neck Injuries": "penetrating injuries to the neck present serious threat primarily due to massive Hemorrhage and Airway compromise resulting from swelling or direct damage to structures such as the lnx or trachea these injuries can cause profuse bleeding if the cored arteries or jugular veins are lacerated leading to a potentially fatal outcome due to significant blood loss another life-threatening complication is the possibility of a fatal air embolism if a large amount of air enters the right atrium and right ventricle of the heart it can lead to Cardiac Arrest to manage this risk immediately seal open neck wounds with an occlusive dressing which helps prevent air from entering the vascular system however care must be taken to avoid constricting the vessels and other structures of the neck be vigilant for signs of swelling and expanding hematomas which may indicate worsening bleeding or Airway compromise in the management of penetrating neck injuries apply pressure both above and below the wound to control life-threatening bleeding if an object is impaled in the neck do not attempt to remove it as this could cause further damage if the situation warrants maintain cervical spine immobilization to protect the patient prompt transport to a medical facility is essential while in route ensure that the airw remains open administer high flow oxygen and obtain vascular access to prepare for fluid resuscitation or medication administration",
        "Laryngeal Injuries": "laryngeal injuries can occur when the LX is crushed against the cervical spine resulting in soft tissue damage fractures or separation of the fascia open injuries to the linic such as those caused by stabbing or other penetrating trauma can lead to Serious Airway compromise if a penetrating or impelled object is present in the linic it should not be removed unless it obstructs cardiopulmonary resuscitation efforts instead stabilize the impaled object if it is not causing an airway obstruction when assessing any patient with blunt trauma to the anterior neck maintain a high index of Suspicion for potential lary injury and perform a thorough evaluation to rule out serious complications signs and symptoms of lenial injuries include a range of indications due to the critical nature of the area involved these symptoms often signal significant trauma and require immediate medical attention esophageal perforation is a serious complication that can lead to mediastinitis a potentially life-threatening infection of the mediastinum if the Linex is injured there's also a high likelihood of cervical spine injury in such cases patients should be advised to avoid shaking their head to prevent further damage managing laryngo and or tracheal injuries involves the following steps provide oxygen and ventilation to ensure the p patient maintains adequate respiratory function apply a cervical collar that you should avoid rigid collars as they can exacerbate the injury closely monitor for the need of frequent suctioning as Airway secretions can accumulate and do not delay transport if the patient is apnic or requires Advanced Airway placement call for paramedic backup to assist with securing the airway",
        "Muscular Injuries to the Neck": "muscular injuries to the neck particularly from non-penetrating trauma are commonly classified as sprains and strains a sprain involves the stretching or tearing of ligaments often accompanied by muscle contraction as the body attempts to stabilize the neck due to the potential for cervical spine involvement always maintain a high index of Suspicion and provide appropriate cervical spine stabilization a strain is the stretching or tearing of muscles or tendons with Whiplash being a common form of cervical strain it's recommended to transport patients to the Ed for radiologic studies to rule out more serious injuries during initial assessment conduct a thorough visual inspection for any signs of soft tissue injury if muscular skeletal injury to the neck is suspected address Airway ventilation and oxygenation needs promptly while ensuring there is no major circulatory compromise in managing muscular injuries to the neck focus on preventing further injury by restricting the patient's range of motion this is typically achieved through the application of a cervical spine stabilization and full body splint additionally check distal pulse sensory and motor function both before and after applying a full full body splint to ensure that no additional neurovascular compromise occurs as a result of the stabilization measure patients who report neck pain should always be thoroughly evaluated for occult injuries even if initial signs are not severe early detection is important to prevent long-term complications that may arise from untreated cervical spine or soft tissue injuries",
        "Prevention of Face and Neck Injuries": "injur prevention measures such as helmets face Shields mouth guards and safety aear are effective tools for reducing the risk of facial head neck and eye injuries additionally advancements in vehicle safety including improved occupate safety restraints and airbags help prevent contact with the interior of vehicles during collisions reducing the risk of trauma further improvements in headrest design have been shown to significantly reduce the number of neck strains particularly those related to whiplash injuries from rear-end collisions these preventative measures play a vital role in minimizing the severity and frequency of injuries in both everyday activities and high-risk environments",
        "Conclusion": "face and neck injuries are frequently encountered in trauma and present a range of challenges for emergency medical professionals these injuries can vary in severity from superficial soft tissue damage to life-threatening complications such as Airway obstruction or significant Hemorrhage the face is particularly vulnerable due to its high vascularity and fractures of facial bones can result in complications such as Airway compromise or neurological development managing these injuries requires prioritizing Airway control cervical spine stabilization and rapid assessment of potential underlying fractures additionally open injuries in the neck may introduce the risk of air embolisms or cause profuse bleeding from damaged vessels soft tissue injuries to the face and neck often result from blunt force or penetrating trauma and their management focuses on controlling bleeding and preventing further damage to critical structures such as the airway the rich blood supply in these areas can result in significant hemorr and swelling making early recognition and intervention essential for instance foreign objects impaled in the eye or other facial structures require stabilization without removal and the airway must be closely monitored for potential compromise proper dressing and immobilization are vital as is the need for Rapid transport to a medical facility for definitive care specific injuries such as fractures of the zygomatic bone mandible or maxilla as well as lingot trauma can result in both cosmetic and functional impairments in such cases careful management is required to prevent long-term complications including respiratory distress or structural deformities the prevention of further damage through mobilization along with early interventions such as oxygenation and fluid resuscitation is Paramount in reducing the risk of mortality or permanent disability"
    },
    {
        "Introduction to Chest Injuries": "chapter 31 chest injuries thoracic injuries contribute significantly to trauma related morbidity IM mortality accounting for a substantial number of fatalities each year approximately one in4 trauma related deaths is directly caused by thoracic trauma with motor vehicle crashes representing the most common mechanism of injury among these patients thoracic injuries are common and can result in serious outcomes if not addressed promptly injuries that impair normal respiratory function require immediate intervention to prevent complication prevention strategies include gun safety education proper Sports training and the use of seat belts which can reduce the incidence of these injuries",
        "Anatomy of the Thoracic Cavity": "the thoracic cavity extends from the lower end of the neck down to the diaphragm it houses vital structures within the media stum which is the central region of the thorax media stum contains the heart great vessels a esophagus lymphatic channels trachea main stem bronchi and the paired vagus and frenic nerves the thoracic organs are partially protected by the rib cage the ribs are connected posteriorly to the 12 thoracic vertebrae and anteriorly by the sternum through the coastal cartilages providing both structure and protection to the thoracic contents the muscles of the thorax not only protect the underlying organs but also help facilitate respiration the primary muscles responsible for breathing are the intercostal muscles and the diaphragm while the Sterno cloid mastoid muscles act as accessory muscles during labor breathing Additionally the trapezius rhomboids and lasus dorsi muscles cover the framework of the posterior thorax while the pectoralis major muscle surrounds the rib cage interiorly providing further structural support the trachea is positioned in the middle of the neck and bifurcates at the Corina into the left and right main stem bronchi the lungs fill the thoracic cavity with the exception of the mediastinum the esophagus enters the thorax via the thoracic Inlet and travels through the posterior chest connecting the fex to the stomach and abdomen lastly the diaphragm forms the interior border of the thoracic cavity and serves as a superior border of the abdominal cavity assisting in respiration in separating these two regions the diaphragm receives its innervation from the frenic nerves which exit the spinal cord at the levels of C3 C4 and C5 these nerves are essential for diaphragmatic movement and consequently for Effective respiration damage to these nerves or to the spinal cord at this level can impair the diaphragms function leading to significant respiratory compromise",
        "Mechanics of Ventilation and Circulation": "ventilation is achieved through the expansion and contraction of the thoracic cage during inspiration the intercostal muscles between the ribs contract and the diaphragm contracts and moves downward allowing the thoracic cavity to expand this process is active requiring muscular effort expiration on the other hand is passive occurring when the intercostal muscles and diaphragm relax allowing the tissues to return to their resting positions while pulmonary ventilation occurs blood is delivered via the pul ponary circulation to capillaries adjacent to the Alvi facilitating gas exchange oxygenation refers to the delivery of oxygen from the air into the bloodstream the ability of the cardiovascular system to pump blood effectively relies on several factors a functional heart as the pump an adequate volume of blood and minimal resistance or afterload against which the the heart must pump cardiac output refers to the volume of blood delivered to the body in one minute which is a key measure of the heart's pumping efficiency ventilation on the other hand describes the exchange of air between the lungs and the external environment which is essential for maintaining oxygen and carbon dioxide balance the rate and depth of breathing are influenced by chemical changes in the body particularly fluctuations in carbon dioxide and oxygen levels chemo receptors which are specialized sensors that detect these chemical changes are located in two major regions of the body and regulate respiratory function by signaling the brain to adjust breathing accordingly increased levels of carbon dioxide are primarily detected by Central chemo receptors that are located in the brain stem which regulate respiratory activity in response to Rising CO2 concentrations",
        "Acid-Base Balance and Respiratory Function": "hyperventilation can lead to respiratory alkalosis a condition where excessive carbon dioxide is expelled resulting in decreased carbonic acid levels in the blood and an increase in PH conversely if bicarbonate is lost as seen in renal excretion metabolic acidosis may occur where the body struggles to maintain a normal PH range the images on the screen highlight the delicate balance between the carbonic acid and bicarbonate with hyperventilation causing the loss of carbonic acid and potentially leading to alkalosis while renal loss of bicarbonate contributes to acidosis respiratory acidosis occurs when the body is unable to effectively remove carbon dioxide o side leading to its accumulation in the bloodstream this condition is often a result of impaired pulmonary function where the retention of carbonic acid leads to a drop in PH in contrast the body May compensate by forming additional bicarbonate and an attempt to balance the pH but if the accumulation of carbonic acid persists it can lead to a worsening of the acidosis here we see an image depicting the balance between bicarbonate and carbonic acid in maintaining the body's pH illustrating how impaired CO2 elimination can tip the scales towards acidosis changes in the arterial pH can directly affect respiratory rate and depth as the body attempts to restore acid base balance ventilation is adjusted in response to pH fluctuations which are detected by peripheral chemo receptors located in areas such as the cored bodies and aortic arch in the case of metabolic alkalosis or the blood becomes too alkaline the respiratory rate and depth decrease as the body tries to retain more CO2 in an effort to lower pH levels back towards normal these mechanisms demonstrate the close link between respiratory function and pH regulation within the the body",
        "Mechanisms of Thoracic Trauma": "thoracic trauma can be categorized into two main mechanisms of injury blunt and penetrating these twois can further result in either open or closed chest injuries closed chest injuries occur when the force is distributed over a large area often resulting in visceral damage from De acceleration shearing forces compression or or rupture open chest injuries result from penetrating trauma where forces are concentrated over a smaller area leading to direct damage to the thoracic structures blunt trauma commonly results in fractured ribs sternum or whole sections of the chest wall as well as bruising to the lungs and heart the aorta may also be damaged in blunt force incidents fractured ribs pose an additional risk as they can lacerate intrathoracic organs furthermore in severe cases of blunt trauma vital organs within the thoracic cavity can be torn from their attachments without any external skin break leading to potentially life-threatening internal injuries",
        "Blast Injuries and Their Impact": "blast injuries present unique challenges and are typically divided into multiple phases during the primary blast a shock wave compresses the thoracic organs in a manner similar to blunt trauma potentially causing significant internal damage without external signs of injury this compression can result in contusions ruptures or other blunt force trauma to the lungs heart and blood vessels in the secondary phase of a blast injury debris and other objects propelled by the blast May strike and penetrate the body body causing additional open or penetrating injuries these combined effects make blast injuries particularly complex and potentially devastating injury to the chest has the potential to be life-threatening due to factors such as blood loss pressure changes and damage to vital organs or a combination of all of these such injuries significantly increase the risk of hypovolemia and hypox which can quickly lead to further complications",
        "Complications of Chest Injuries": "decreased lung volume and impaired oxygenation Place additional stress on the heart reducing its ability to pump effectively accumulation of blood in the paracardial sac known as cardiac tampeno compresses the heart which can ultimately lead to Cardiac Arrest damage to myocardial valves can interfere with proper ventricular filling and vascular disruptions further complicate the situation impairments and ventilatory efficiency can also prove rapidly fatal due to decreased air exchange and oxygenation reduced minute volume and the development of conditions such as num thorax and hemothorax additionally a decreased tidal volume can severely impact the body's ability to maintain adequate oxygenation in ventilation thus exacerbating the sever it of the injury adelais occurs when Alvi collapse preventing a portion of the lung from participating in ventilation and oxygenation this condition significantly reduces the surface area available for gas exchange impairing the body's ability to oxygenate the blood effectively additionally bruised lung tissue can exacerbate this issue leading to marked hypoxemia due to impaired oxygen transfer in more severe cases disruption of the respiratory tract can prevent oxygen from reaching the LV altogether further compromising the patient's respiratory function and leading to potentially life-threatening hypoxia",
        "Signs and Symptoms of Chest Injuries": "the signs and symptoms of chest injury can often be subtle making early recognition critical patients May exper exp erience pain at the sight of injury which is typically localized and worsens with breathing additional signs include bruising of the chest wall crepitus upon palpation and visible penetrating injuries dnia is a common symptom and Hema typis may be present in more severe cases failure of the chest to expand normally during inspiration is a concerning sign as a rapid weak pulses and low blood pressure cyanosis around the lips or fingernail beds is an indicator of poor oxygenation and any noticeable change in breathing patterns such as fewer than 12 breaths per minute or more than 20 breaths per minute may suggest inadequate breathing patients with chest injuries often present with teyia in Shallow respirations though in some cases bradia and labored respirations may also occur disia can result from several causes including Airway obstruction damage to the chest wall improper chest expansion or lung compression hemo tipis occurs when the lung Paran or air passages have been damaged allowing blood to enter the bronchial passages the presence or absence of a pulse may vary depending on the nature and extent of the injury the absence of radial pulses generally indicate severe hypotension and tacac cardia often signals compensatory shock or hypoxemia while brto cardia is typically an ominous sign suggesting a worsening condition or impending Cardiac Arrest changes in blood pressure can vary significantly depending on the nature and extent of the chest injury hypertension may be caused by an increased sympathetic discharge in response to trauma while hypotension is typically a sign of hypovolemia relative hypovolemia or even late stage shock a narrowed pulse pressure suggest increased pressure on The myocardium often due to conditions such as cardiac tanod the loss of peripheral pulses during inspiration known as pulses paradoxus is yet another sign of cardiac tanod in some cases patients may also present with hypothermia particularly those in neurogenic shock resulting from a spinal cord injury diaphoresis and poer are common indicators of peripheral Vaso constriction and cyanosis is a clear sign of inadequate respiration providers should keep in mind that these signs and symptoms often occur simultaneously highlighting the need for prompt transport and aggressive treatment of patients with chest injuries",
        "Rib Fractures and Associated Risks": "rib fractures are less common in children due to the pliability of their thoracic cage but they occur more frequently in older patients whose bones may be more brittle rib fractures of the upper four ribs are relatively rare because these ribs are well protected by the clavicle and scapula when such fractures do occur they usually indicate a severe mechanism of injury the morbidity and mortality associated with rib fractures increase with patient age the number of fractures and the specific location of the fractures a fractured rib can also potentially El acerate the surface of the lung leading to complications such as subcutaneous osma which is characterized by a crackly feeling under the skin due to air escaping from the injured lung and accumulating in the subcutaneous tissue ribs 4 through n are the most commonly fractured patients with rib fractures typically attempt to split the injury using their arm and take shallow breaths to minimize chest movement and pain adala Tois is often a consequence of rib fractures severe trauma to the first and second ribs may result in significant injuries such as a ruptured aorta tracho bronchial tree injury or vascular damage trauma to the left lower ribs can also be associated with spleen injury while trauma to the right lower ribs may lead to liver injury multiple rib fractures increase the risk of atal acasis hypoventilation inadequate coughing and pneumonia posterior fractures most commonly affect the fifth through 9th rib floating ribs although well protected and rarely fractured suggest a severe mechanism of injury when damaged often indicating the potential for other life-threatening injuries rib fractures place the patient at risk for numerous Associated injuries with patients typically reporting localized tenderness and pain on breathing",
        "Flail Chest and Its Management": "flail chest occurs when a segment of the chest wall becomes detached from the rest of the thoracic cage creating a free floating segment that moves independently during respiration this injury is typically caused by significant trauma such as motor vehicle collisions Falls from substantial Heights industrial accidents or assault the severity of the trauma required to produce a flail segment is considerable mortality rates associated with flail chest increase in cases involving Advanced age the presence of seven or more fractured ribs three or more Associated injuries shock or head injury flil chest significantly impairs the ability to maintain adequate oxygenation as the free floating segment disrupts the mechanics of normal breathing and reduces respiratory efficiency respiratory failure in a patient with a flail chest typically results from other Associated injuries such as pulmonary contusion pneumothorax or hemothorax it's important to expose and thoroughly examine the chest for any Decat btls management of flail chest focuses on assessing the need for positive pressure ventilation and administering oxygen as necessary if ventilations are inadequate positive pressure ventilation should be initiated restricting chest wall movement once a common practice is no longer recommended in the management of flil chest",
        "Sternal and Clavicle Fractures": "a sternal fracture results from a blow significant enough to cause severe hyper flexation of the thoracic cage while isolated sternal fractures have a relatively low mortality rate the risk of death increases with additional injuries and advanced age sternal fractures can lead to pulmonary and myocardial contusions flail chest and other Associated injuries patients typically present with localized pain and tenderness over the sternum along with crepitus on palpation teia is also common in these cases it's important to maintain good respiratory status and monitor closely for any respiratory or cardiovascular changes when providing ventilations avoid overly aggressive techniques that may worsen the injuries establish IV access but administer fluids cautiously an isotonic crystalloid solution can be used to maintain the systolic pressure between 80 and 90 to help reduce thoracic pressure and facilitate lung expansion Elevate the head of the long backboard if the patient is in full spinal protocol a clavical fracture is one of the most commonly fractured bones in the body frequently occurring in children who fall on an outstretched hand or as a result of crushing injuries to the chest patients with a clavical fracture typically report pain in the shoulder and may hold their arm across the front of their body to reduce movement and pain this type of fracture can be effectively managed by splinting the affected area using a sling and swave which helps stabilize the arm and minimize discomfort",
        "Commotio Cordis": "kiotis is a rare but life-threatening condition that occurs when the chest receives a direct often forceful blow during a specific vulnerable moment in the heart's electrical cycle specifically during the repolarization phase of the cardiac Rhythm this precise timing can trigger ventricular fibrillation leading to immediate cardiac rest even in the absence of pre-existing heart conditions or significant thoracic trauma the blow typically occurs in sports like baseball hockey or lacrosse where projectiles or physical contact directly impact the chest when ventricular fibrillation occurs the heart's ability to pump blood effectively ceases leading to a rapid loss of consciousness and without intervention death death the key to survival in kiotis is prompt recognition and Rapid intervention especially early defibrillation studies show that if defibrillation is provided within 3 minutes of the event the chances of restoring a viable heart rhythm increase significantly and often lead to better outcomes this highlights the importance of having access to aeds in public spaces particularly in sports arenas in schools where youth contact sports are played survival rates in Kio Cordis are not solely determined by medical intervention they're also influenced by public awareness of the condition widespread CPR training and immediate access to defibrillators increasing awareness about the condition in sports communities can lead to faster responses when such an incident occurs in addition advancements in Protec acve gear such as chest protectors designed to disperse the impact force and reduce the likelihood of triggering kortis have become a critical part of injury prevention strategies although no gear can guarantee full protection well-designed protective equipment can reduce this risk significantly",
        "Pneumothorax and Its Variants": "a simple pneumothorax occurs when air enters the plural space through a hole in the chest wall or the surface of the lung often as the patient attempts to breathe this results in a buildup of pressure within the plural space in many cases particularly with low velocity injuries the wound May self seal limiting the extent of the Numa thorax however the amount of air that accumulates and the severity of the Numa thorax can vary widely a spontaneous numor should be suspected in patients who experience sudden sharp chest pain in shortness of breath without a known traumatic cause in some cases a patient who takes a deep breath just before experiencing blunt chest trauma May develop what is known as paper bag syndrome where the lung ruptures due to the rapid compression of the air filled lung the location of air accumulation depends on on the patient's position in a standing patient air tends to rise and collect in the opposes of the lungs whereas in a Seine patient it gathers in the anterior portion of the chest tracheal deviation is a very late sign of pneumothorax and is rarely seen especially in cases of simple pneumothorax the accumulation of air can lead to compression of the lungs myocardium and great vessels causing a mismatch in ventilation and profusion the clinical presentation and physical findings will depend on the size of the pneumothorax and the degree of pulmonary compromise common signs include teyia and teoc cardia reflecting the body's attempt to compensate for reduced oxygen exchange as the pressure in the plural space increases due to a num thorax chest wall movement decreases which can impair ventilation upon percussion hyper resonance may be detected indicating the presence of air in the plural cavity as the size of the pneuma thorax increases the degree of respiratory and cardiovascular compromise also worsens it's important to immediately cover any open chest wounds with an inclusive dressing to prevent f further air from entering the plural space positive pressure ventilation should be used sparingly as excessive use can exacerbate the condition by increasing intrathoracic pressure frequent reassessment of the patient is critical if signs and symptoms suggest the development of attention Numa thorax such as increasing respiratory distress or tracheal deviation it may be necessary to remove the occlusive dressing and allow the trapped air to escape in cases where the patient shows signs of cardiac dysrhythmia or tension num thorax it's essential to call for paramedic backup as advanced interventions such as needle decompression may be required to stabilize the patient",
        "Open Pneumothorax": "an open pneuma thorax occurs when there's an open injury to the chest wall allowing communication between the plural space and the external atmosphere this disrupts the normal development of negative intra plural pressure causing part of the lung to collapse as a result hypoventilation occurs due to increased pressure in the plural space and the reduced surface area available for gas exchange hypoxia follows because less oxygen is available for the bloodstream during inspiration air enters the plural space and while some air May exit during exhalation it may also remain trapped further complicating the situation if the lung parena has been penetrated direct lung injury may also be present which can exacerbate respiratory compromise in some cases the vena may become kinked due to increased intrathoracic pressure which reduces Venus return to the heart or preload this consequently decreases cardiac output and worsens the patient's condition in an open pnea thorax air movement may be detectable as the patient inhales and exhales a characteristic sucking sound is often heard during inhalation which is why an open or penetrating wound to the chest wall is frequently referred to as a sucking chest wound as respiratory distress increases the patient commonly develops tacac cardia and Topia in an attempt to compensate for the decreased oxygenation caused by the compromised lung function in cases of open pneuma thorax additional signs may include subcutaneous empyema and decreased breath sounds on the affected side as well as signs of hypovolemia imposs cardiac dysrhythmias immediate treatment is critical for sucking chest wounds first place a gloved hand over the wound to prevent further air entry then replace this with an inclusive dressing or a commercial chest seal securing it on three sides to allow trapped air to escape while preventing more air from entering management follows the same principles as for a simple num thorax when applying an eclusive dressing it's important to document the type of material used whether three or four sides were sealed and any changes in the patient skin color Vital Signs breath sounds or if they begin to experience respiratory distress continuous monitoring is essential and if the patient's condition worsens indicating a potential tension to my thorax the occlusive dressing may need to be burped to release trapped air",
        "Tension Pneumothorax": "a tension Numa thorax occurs when increasing pressure within the plural space causes the collapse of the affected lung and shifts the mediastinum to the opposite plural cavity this shift compresses the heart and great vessels leading to a compromised cardiac output and oxygenation classic signs of attention pneuma thorax include the absence of breast sounds on the affected side unequal chest rise and pulse paradoxus teoc cardia and dysrhythmias are also common as the condition worsens the increasing pressure within the thoracic cavity causes blood to accumulate within the great vessels just outside the thoracic cage further impeding circulation diminished breath sounds on the affected side and ptic chest pain along with dnia are commonly reported by patients in managing attention pneumat thorax focus on maintaining the ABCs while ensuring prompt intervention to relieve the pressure such as needle decompression if indicated and available it's important to cover any open chest wounds immediately with an eclusive or non-porous dressing to prevent further air entry however if signs of developing tension num thorax such as increasing respiratory distress or worsening hemodynamics are observed lift one corner of the dressing to allow trapped air to escape early activation of paramedic backup is essential as they can perform a needle chest decompression",
        "Hemothorax and Hemopneumothorax": "a hemothorax occurs when blood accumulates in the space between the parial and visceral plora the membranes surrounding the lungs this condition often results from tears in the lung parena penetrating wounds that puncture the heart or major vessels within the mediastinum or blunt trauma that causes de acceleration shearing of major vessels or intercostal vessels rib fractures especially those that involve the lung parena can also contribute to the development of a hemothorax a massive hemothorax is defined as the accumulation of more than 1500 MLS of blood within the plural space this significant blood loss can rapidly lead to decompensated shock and in severe cases it's possible that a patient completely exanguination of hypoxia and hypotension develops quickly as the lungs are compressed by the accumulating blood and the body's ability to circulate oxygenated blood diminishes hemothorax should be suspected in any patient presenting with signs and symptoms of shock particularly if there are decreased breath sounds on the affected side common signs and symptoms include Topia tacac cardia dnia and overall respiratory distress hypotension a narrowed pulse pressure and pidit chest pain may also be present phys physical findings often include pale cool moist skin dullness on percussion decreased or unequal breath sounds and either flat or distended neck veins depending on the severity of the shock a hemon numo thorax is a condition where both air and blood accumulate within the plural space leading to a combination of lung collapse and compression due to the PO cooling of blood this dual accumulation further exacerbates the respiratory compromise and circulatory instability as the presence of air reduces lung capacity and the blood loss increases the risk of hypovolemic shock clinically the signs and symptoms of hemon Numa thorax include those typically seen in both pneumothorax and hemothorax these may include diminished or absent breath sounds on the effect Ed side respiratory distress pic chest pain teyia tachicardia and signs of shock such as hypotension narrowed pulse pressure and cool pale skin percussion over the affected area May reveal hyperresonance or dullness depending on the extent of each component management focuses on addressing both respiratory and circulatory compromise as usual the first priority is to maintain the ABCs oxygen should be administered immediately and if the patient's respiratory effort is inadequate positive pressure ventilation may be required that being said it should be used cautiously as excessive pressure can exacerbate the air accumulation in the plural space increasing intrathoracic pressure and worsening the pneuma thorax if if the patient does show signs of hypovolemia such as hypotension teoc cardia or poor peripheral profusion a fluid bullet should be administered to restore circulatory volume and stabilize the patient's blood pressure the goal of fluid resuscitation is to improve perfusion while avoiding over resuscitation which could increase the risk of further bleeding",
        "Pulmonary Contusion": "pulmonary contusion is the most common injury resulting from blunt thoracic trauma and is frequently associated with rib fractures it should be suspected in patients with flail chest as both conditions commonly occur together however pulmonary contusion is often overlooked due to the presence of other significant Associated injuries so a high index of Suspicion is needed especially when the mechanism of injury suggests blunt chest trauma the pathophysiology of pulmonary contusion can be explained through three main mechanisms the implosion effect occurs when the air in the lungs overexpanded to a sudden pressure wave leading to Rapid and excessive stretching and tearing of the Alvi the inertial effect involves a separation of the Alvi from heavier brochi structures as the Alvi are pulled at varying rates by the pressure wave which further damages lung tissue lastly the spalling effect refers to the disruption of the liquid gas interface or exchange within the lungs caused by the impact of the shock wave this disruption impairs gas exchange contributing to respiratory compromise pulmonary contusion results in Alvar and capillary damage leading to interstitial and intra alv Hemorrhage this bleeding impairs gas exchange causing hypoxia and carbon dioxide retention as a result patients may experience respiratory distress characterized by disia Topia and symptoms of agitation or restlessness due to inadequate oxygenation on oscilation breath sounds may vary depending on the extent of the contusion you may hear wheezes Rock eye or crackles or in severe cases breast sounds may even be diminished in the affected area due to the accumulation of fluid and compromised lung function treatment for pulmonary contusion is primarily supportive focusing on maintaining adequate oxygenation and ventilation while iy fluids may be necessary to support cardiac output they should be administered cautiously and in small amounts as excessive fluid administration can exacerbate pulmonary edema and worsen respiratory distress",
        "Cardiac Tamponade": "cardiac tampeno which can also be referred to as paracardial tampeno occurs when blood or other fluids collect within the pericardium which is the sac surrounding the heart this accumulation of fluid prevents the heart from filling properly during the diastolic phase leading to impaired cardiac output and potentially life-threatening consequences although relatively uncommon cardiac tanod is more frequently associated with penetrating injuries to the heart such as stab or gunshot wounds rather than blunt chest trauma the pericardium consists of two layers the visceral pericardium which is directly attached to the heart heart and the parial pericardium which forms the outer Sac the pericardium serves several critical functions including anchoring the heart in place restricting excessive movement of the heart within the chest and preventing the kinking of the great vessels the space between the visceral and parietal layers normally holds anywhere from 30 to 50 MLS of fluid to allow smooth movement of the heart however when excess fluid accumulates such as in a cardiac tampeno the space becomes a dangerous pressure Zone compressing the heart and reducing its ability to function effectively in cardiac tonot even small fluid accumulations of as little as 50 MLS within the pericardium can significantly reduce cardiac output by compressing the heart and restricting its ability to feel during diast this reduction in cardiac output leads to systemic hypo profusion and hypotension which can quickly become life-threatening if not addressed the classic signs are known collectively as Beck Triad which includes a narrowing pulse pressure jugular Venus distension and muffled heart tones however these signs often appear in the later stages of tanod making early detection more challenging the physical findings in the early stages of cardiac tanod may not differ significantly from those seen in tension neuma thorax such as a decrease in breath sounds tachicardia and respiratory distress management begins with a focus on the ABCs initiate large bore IV access and provide a rapid fluid bolus to maintain systolic blood pressure in the range of 80 to9 90 ensuring adequate profusion until definitive care can be provided rapid transport is crucial and paramedic backup should be requested for managing potential dysrhythmias that may occur due to the compromised heart function ultimately the definitive treatment for cardiac tamponade is paric cardio centesis a procedure where fluid is aspirated from the paracardial sac to relieve the pressure on the heart this intervention is typically performed in a hospital setting but emergency transport and support are critical in stabilizing the patient in rout",
        "Myocardial Contusion and Rupture": "myocardial contusion is a bruising of the heart muscle that typically results from blunt trauma to the chest such as from motor vehicle collisions or Falls this injury can also lead to vascular damage within the heart which may cause delayed complications such as rupture or the development of a ventricular aneurysm in more severe cases myocardial contusion can result in right or left-sided heart failure depending on the area of the heart that's affective clinical signs of myocardial contusion will vary based on specific location and the severity of the injury it's often associated with other traumatic injuries such as 1 to three rib fractures or a sternal fracture which can provide clues to the diagnosis patients may present with retrosternal chest pain though this can be absent and external signs of trauma may or may not be visible on oscilation crackles may be heard especially if pulmonary edema is present and the pulse may be irregular due to the impact on the cardiac conduction pathways management involves providing supportive care including monitoring for signs of hemodynamic instability and ensuring that ABCs are maintained providers should assess for jvd and pulmonary edema both of which indicate cardiac compromise early activation of paramedic backup is essential as the condition can rapidly deteriorate and advanced cardiac monitoring or interventions May be necessary careful observation is required to detect any signs of Rapid deterioration such as worsening chest pain arrhythmias or signs of heart failure which may necessitate immediate intervention myocardial rupture is the acute perforation of one or more structures of the heart including the ventricles Atria intraventricular septum intraatrial septum cordate tendon papillary muscles or heart valves this condition is typically caused by severe blunt trauma to the chest where the heart is compressed between the sternum and vertebrae or by penetrating injuries that directly damage the heart myocardial rupture is a life-threatening event that requires immediate recognition and intervention patients may present with acute pulmonary edema indicating left heart failure or with signs of cardiac tamponade such as jvd hypotension and muffled heart sounds the rapid accumulation of blood within the pericardium or sudden heart failure due to structural damage can quickly lead to circulatory collapse prompt identification of myocardial rupture is critical as the condition is almost always fatal without rapid surgical intervention prehospital management focuses on maintaining ABCs and providing rapid transport to a facility that's capable of Performing emergency cardiac surgery",
        "Traumatic Aortic Disruption": "traumatic aortic disruption or the rupture of the aorta is a severe and often fatal injury that most commonly occurs as a result of blunt trauma particularly in motor vehicle collisions or Falls from significant Heights the aorta is its most vulnerable at its fixed points such as near the ligamentum arteriosum where shearing forces caused by rapid de acceleration can lead to rupture a high percentage of patients with traumatic aortic disruption may not show external signs of chest trauma making early detection difficult assessment findings may include retrosternal or intercap pain often described as tearing in nature which is a classic sign of aortic injury other symptoms include dnia dysphasia heness or Strider and Es schic pain in the extremities patients may also present with upper extremity hypertension and diminished or absent F moral pulses indicating compromised circulation hypotension and signs of shock are late indicators and signify severe cardiovascular compromise management of traumatic aortic disruption focuses on maintaining the ABCs and ensuring rapid transport to a facility capable of surgical intervention here early recognition and immediate transport is crucial as the condition is life-threatening and requires emergency surgical repair to prevent further deterioration",
        "Penetrating Wounds of the Great Vessels": "penetrating wounds of the great vessels are often associated with traumatic injuries to the chest abdomen or neck these injuries can involve significant blood loss and Rapid deterioration making them particularly life-threatening the major blood vessels contained within the chest include the superior vnea inferior vnea pulmonary arteries four main pulmonary veins and the aorta along with its branches penetrating wounds of the great vessels can lead to massive internal hemorrhage hypovolemic shock and cardiac tanod or the formation of enlarging hematomas which can further complicate the patient's condition by compressing surrounding structures one of the key challenges with these injuries is that the the extent of blood loss may not be immediately obvious externally as much of the bleeding occurs internally hematomas resulting from these injuries can compress vital structures such as the heart lungs or other mediastinal components worsening respiratory and circulatory function due to the rapid potential for deterioration it's critical to transport the patient immediately to the hospital while maintaining the ABC early intervention in a trauma facility is essential for the patient survival",
        "Diaphragmatic Injury": "diaphragmatic injury can result from both blunt and penetrating trauma and it's a life-threatening condition blunt trauma such as from motor vehicle collisions or Falls can cause a sudden increase in intraabdominal pressure due to high Force compression of the abdomen this pressure can lead to several severe complications including bowel obstruction or strangulation as abdominal organs herniate through the diaphragm into the thoracic cavity additionally diaphragmatic injury can restrict lung expansion leading to hypoventilation and hypoxia while also contributing to cardiac and respiratory compromise due to the shifting of abdominal contents into the chest diaphragmatic injuries can be classified into three phases acute latent and obstructive during the acute phase the injury occurs and immediate symptoms may arise the latent phase follows during which symptoms may not be prominent but the risk of complications remains high in the obstructive phase complications such as organ herniation into the thoracic cavity become evident a rare but serious complication is the herniation of abdominal contents into the thoracic cavity leading to a condition known as gastrothorax in this condition The increased intrathoracic pressure compresses the lung on the affected side and compromises circulatory function potentially leading to life-threatening consequences signs and symptoms of diaphragmatic injury include teyia teoc cardia respiratory distress dullness to percussion a scaffo or sunken abdomen the presence of bow sounds in the thoracic cavity and decreased breath sounds on the affected side these findings suggests that abdominal organs have shifted into the chest impacting both respiratory and circulatory function in the prehospital setting elevating the head of the backboard or the stretcher can help keep abdominal contents in the abdominal cavity minimizing their impact on lung function positive pressure ventilation should be provided if the patient shows signs of hypoventilation to support oxygenation and ventilation",
        "Esophageal Injury": "esophageal injury is most commonly caused by penetrating trauma such as stab wounds or gunshot injuries to the neck or chest if undetected esophageal injuries can be life-threatening due to the potential for infection mediaos is or complications from the leakage of gastric contents into surrounding tissues while trauma is the primary cause spontaneous perforation of the esophagus can also occur typically due to Violent emesis carcinoma or anatomic distortions caused by conditions like diverticula or chronic gastric reflux patients with esophageal injuries typically present with pain heness dysphasia respiratory distress and signs of shock these symptoms can vary in severity depending on the extent of the injury in any Associated trauma esophageal injuries particularly perforations present with distinct signs depending on whether the perforation occurs in the cervical or intrathoracic region for cervical esophageal perforations common signs include localized tenderness subcutaneous osma and resistance of the neck to passive movement due to the injury and Associated swelling in the case of intrathoracic perforations signs include mediastinal empyema mediaos sinus subcutaneous osma and a mediastinal crunch which is a crunching sound heard on oscilation which is also known as Hammond sign splinting of the chest wall where the patient attempts to limit chest movement due to pain may also be observed prehospital care for esophageal injuries is commonly supportive with a focus on maintaining the airway breathing and circulation the patient should be rapidly transported to an appropriate facility for definitive surgical intervention as untreated esophageal perforations can lead to life-threatening complications",
        "Tracheobronchial Injuries": "trob bronchial injuries are rare but highly fatal often resulting from either blunt or penetrating trauma to the chest the high mortality rate associated with these injuries is due to the rapid movement of air into the plural space particularly when the injury occurs near a point of attachment such as the trachea or main bronchi this can quickly lead to conditions such as attention Ina thorax or severe respiratory compromise Associated clinical findings include horseness tpia tacac cardia massive sub cutaneous osma dnia and respiratory distress hypsis09 care involves treating the patient symptomatically focusing on maintaining the airway providing oxygen and managing ventilation as needed immediate transport to a facility that's capable of surgical repair is essential for the patient survival",
        "Traumatic Asphyxia": "traumatic asfixia occurs as a result of a sudden severe compression injury to the chest which leads to a rapid and dramatic increase in intrathoracic pressure this forceful compression causes blood to be forced backward from the chest into the Venus system especially affecting the head and neck as a result the jugular veins become engorged and the increased pressure causes capillaries in the face and neck to rupture leading to characteristic petii or cyanosis in these regions this condition is typically seen in incidents involving heavy compression such as motor vehicle collisions or being crushed by heavy objects here we see a common presentation of a patient who has experienced traumatic asphyxia these patients typically present with extended neck veins and cyanosis to the face neck upper extremities and torso above the level of compression a result of the increased Venus pressure swelling and cyanosis of the tongue and lips are also common along with ocular hemorrhages which may vary in severity from mild subc conjunc hematomas to dramatic bulging eyes despite the severe appearance of the upper body the skin below the area of compression remains normal in color as blood flow is not impeded in those regions a critical issue arises when pressure is released as it can lead to sudden hypotension due to the rapid return of blood from the compressed areas to Central circulation immediate recognition and intervention are key in managing traumatic asfixia prehospital management should include rapid transport to a Trauma Center treatment of symptoms such as respiratory distress or shock and maintaining cervical spine precautions due to the likelihood of associated spinal injuries from the trauma IV access should be established with two large bore IV lines to allow for fluid resuscitation and to manage the anticipated hypotension early and aggressive Management in the field can significantly improve outcomes for patients with traumatic asphyxia",
        "Emergency Medical Care for Chest Injuries": "in the emergency medical care of patients with chest injuries stabilizing the airway is the primary management concern providers should begin by evaluating the airway and respiratory status while maintaining cervical spine immobilization as spinal injuries may be present be prepared to suction the patient if necessary and administer high flow oxygen especially if significant bleeding is suspected if the patient requires assistance with ventilation use a bag mask with high flow oxygen it's important to avoid actions that may increase the patient's work of breathing or or cause additional pain treat for shock and provide rapid transport if there are signs of hypo profusion and establish at least one large bore IV catheter administer a 20 ml per kg bolus of isotonic crystalloid solution try trading the fluid administration to maintain a systolic pressure between 80 and 90 always follow local protocols and call for paramedic support for additional Advanced interventions if need thoracic injuries are among the most severe forms of trauma contributing significantly to trauma related deaths with motor vehicle crashes being a leading cause these injuries can compromise respiratory function causing conditions such as pneumothorax or hemothorax where air or blood accumulates in the plural space preventing proper lung expansion immediate management of the airway bring breathing and circulation is critical in the prehospital setting particularly when dealing with significant bleeding reduced ventilation or shock preventative measures like seat belt use gun safety and sports training can help reduce the incidence of thoracic trauma anatomically the thoracic cavity contains vital structures such as the heart lungs gra vessels and esophagus all protected by the rib cage and supported by the intercostal muscles and diaphragm all which facilitate respiration damage to these structures as seen in penetrating or blunt trauma can result in life-threatening conditions such as cardiac tampeno tension Puma thorax or major vessel rupture maintaining oxygenation and circulatory support while preparing for surgical intervention is essential particularly in injuries like myocardial contusion rib fractures and Comm Cordis which may compromise the heart's pumping ability or the lung's capacity to exchange gases effective emergency medical care for chest injuries prioritizes the stabilization of the ABC's early oxygen Administration and careful management of shock through IV resuscitation titrated to maintain optimal blood pressure recognizing life-threatening signs such as sinosis respiratory distress and decreased breath sounds can guide the need for advanced interventions such as positive pressure ventilation or needle decompression particularly in cases of tension in a thorax rapid transport to a trauma facility is key in improving patient outcomes in severe thoracic trauma"
    },
    {
        "Introduction to Orthopedic Injuries": "chapter 33 Orthopedic injuries muscular skeletal injuries are among the most frequent reasons patients seek medical care typically identified by the presence of pain swelling and deformity while these injuries are rarely life-threatening they often result in disability and long-term impairment however when treating these injuries it's important not to focus solely on the obvious injury without first assessing for any life-threatening conditions initial patient assessment must follow the ABC's approach with which includes checking for ex anguina Hemorrhage Airway patency breathing Effectiveness circulatory status disability or neurological assessment and exposure to identify any hidden injuries this ensures that critical systemic issues are not missed during the initial examination of muscular skeletal trauma.",
        "Musculoskeletal System Functions": "The muscular skeletal system provides the body with its structure and Facilities movement bones form a framework that not only give the body shape but also allows it to maintain an upright posture additionally bones play a protective role by safeguarding more fragile organs and structures beneath them movement is generated when a muscle contracts and the force from the muscle is transferred to a bone on the opposite side of a joint this coordinated action between muscles and Bones enables Locomotion and other physical activities another critical function of the muscular skeletal system is hematopoesis the process by which R blood cells are produced within the bone marrow playing a vital role in maintaining the body's overall health and function.",
        "Muscle Types and Functions": "Muscles are composed of specialized cells that contract when stimulated producing force that moves various parts of the body there are three distinct types of muscles cardiac skeletal and smooth cardiac muscle is found in the heart skeletal muscle is responsible for voluntary movements and smooth muscle controls involuntary actions within the organs muscle contraction does require energy which is obtained through glucose metabolism resulting in the production of lactic acid as a byproduct skeletal muscles are inated by sematic motor neurons and the combination of a muscle and its corresponding neuron forms a motor unit to generate a stronger muscle contraction more neurons must signal additional muscle cells a process known as recruitment.",
        "Blood Supply to Muscles": "The blood supply to skeletal muscles is provided by arteries veins and nerves in the upper extremities the blood supply originates from the subclavian artery while in the lower extremities it arises from the external iliac arteries this extensive vascular Network ensures that muscles receive adequate oxygen and nutrients to function effectively during contraction and movement.",
        "Human Skeleton Structure": "The human skeleton is composed of approximately 206 bones and is divided into two main parts the axial skeleton and the appendicular skeleton the axial skeleton consists of the bones that form the central axis of the body body including the skull vertebral column and rib cage these bones provide structural support and protect vital organs such as the brain spinal cord and thoracic organs the appendicular skeleton on the other hand includes the bones of the pectoral girdle pelvic girdle and the upper and lower extremities the pectoral girdle connects the upper limbs to the Torso while the p girdle anchors the lower limbs together these structures facilitate movement allow for the attachment of muscles and support the overall function of the muscular skeletal system.",
        "Upper Extremity Anatomy": "The upper extremity is composed of three main regions the upper arm elbow and forearm the bones of the forearm consist of the radius andna which work together to enable a wide range of motion in the arm the hand is made up of three distinct sets of Bones the wrist is formed by the carpal while the metac cares make up the bones in the hand itself the fingers are composed of the fanges allowing for fine motor functions and dexterity required for grasping and manipulating objects these structures work in concert to enable complex movements and tasks involving the upper extremity.",
        "Pelvis and Lower Extremity Anatomy": "The pelvis serves a dual function of supporting the body's weight and protecting the internal organs located within the pelvic cavity the pelvic girdle is composed of three separate Bones the isum ilium and pubis that fuse together to form the innominate or hip bone this Fusion creates a strong and stable structure that connects the lower limbs to the axial skeleton the two iliac bones are connected posteriorly to the stum at the sacr iliac joints through a series of ligaments providing stability and allowing for limited movement these joints play a key role in weightbearing and balance during standing walking and other movements the two pubic bones are connected anteriorly by ligaments at the pubic symphysis a fibrocartilages joint that provides stability to the pelvic girdle the lower extremity consists of bones of the thigh leg and foot which together support body weight and allow for Locomotion the lower leg is composed of two bones the tibia and fibula the fibula serves as an attachment point for the lateral ligaments of the knee joint and acts as the lateral stabilizer of the ankle joint at its distal articulation the foot contains three classes of Bones the tarsel which form the ankle the metat tarel which make up the body of the foot and the fanges which constitute the bones of the toes these structures enable a wide range of motion and support during standing and movement.",
        "Joint Function and Classification": "A joint is formed at any point where two bones come into contact serving as the connection that facilitates movement between them joints allow various types of motion depending on their structure these motions include flexation which decreases the angle between two bones and extension which increases this angle abduction refers to moving a limb away from the midline of the body while adduction is the movement of a limb toward the midline rotation is a circular move around an axis and circumduction is a conical movement of the limb pronation involves the inward rotation of the forearm or foot and subnation is the outward rotation these movements enable the body to perform a wide range of functions from simple daily tasks to complex athletic activities.",
        "Bone Classification and Structure": "Bones are classified based on their shapes long bones such as those in the arms and legs are longer than they are wide providing strength and leverage short bones found in areas like the wrists and ankles are nearly as wide as they are long offering stability with limited movement flat bones such as the ribs and skull are thin and Broad serving protective functions irregular bones like the vertebrae have complex shapes to support support various functions sesamoid bones such as the patella are round and generally found embedded in tendons where they modify pressure and reduce friction long bones are structured into three main regions the diaphysis or shaft the epiphysis or inss and the metaphysis or growth plate region where two bones meet to form a joint the ends are covered by a thin layer of articular cartilage reducing friction and facilitating smooth movement the rest of the bone surface that's not covered by cartilage is encased by the periostium a dense fibrous membrane that supports bone health and repair the inner portion of the long bone receives this blood supply from the nutrient artery which penetrates deep into the bone providing essential nutrients for bone maintenance and growth.",
        "Connective Tissue Roles": "Tendons ligaments and cartilage play important roles in the muscular skeletal system tendons connect skeletal muscles to bones allowing for the transfer of force between them when muscles contract this Force enables Movement by pulling bones across joints ligaments on the other hand connect bone to bone helping to stabilize joints and control the range of motion by preventing excessive movement cartilage a resilient tissue made of collagen fibers embedded in a gelatinous matrix provides cushioning and smooth surfaces at joints reducing friction and absorbing shock during movement.",
        "Aging and Musculoskeletal Changes": "As we age particularly after the age of 35 bone density naturally begins to decrease this reduction in bone density can result in a gradual loss of height and noticeable changes in facial structure in women the decline in bone density accelerates significantly after menopause due to hormonal changes a more pronounced decrease in bone density known as osteoporosis is associated with an increased risk of fractures as bones become more fragile Additionally the aging process affects muscles cartilage and other connective tissue issues potentially leading to Joint degradation and conditions such as disc herniation further impacting mobility and overall health.",
        "Causes of Musculoskeletal Injuries": "Muscular skeletal injuries can result from both blunt and penetrating trauma sports injuries account for a large portion of these cases often involving fractures or sprains in children fractures and other muscular skeletal injuries May sometimes result from intentional trauma or abuse another type of injury known as a pathologic fracture occurs when a bone becomes abnormally weak due to an underlying medical condition making it more susceptible to Breaking with minimal Force the mechanism of injury is an important consideration in muscular skeletal trauma significant force is usually required to cause fractures or dislocations and this force can be applied in various ways direct blows such as those experienced in contact sports or accidents are a common cause indirect forces such as those transmitted along the length of a limb twisting forces from Sudden rotational movements and high energy injuries like those seen in motor vehicle collisions can all result in damage to bones and joints.",
        "Fracture Types and Classifications": "Fractures occur when the force applied to a bone exceeds its structural strength leading to a break there are several classifications of fractures including open and closed an open fracture also referred to as a compound fracture occurs when there is a break in the overlying skin exposing the bone and Fracture site to the external environment increasing the risk of infection in contrast a closed fracture involves no break in the skin keeping the fracture isolated from the outside environment fractures can also be described based on alignment angulation occurs when the fractured bone fragments are misaligned forming an angle between the broken ends in a non-displaced fracture the bone is simply cracked but the fragments remain in their normal anatomical position conversely in a displaced fracture the bone ends are separated in at least one plane requiring realignment for proper healing.",
        "Fracture Patterns and Management": "Various terms are used to describe the types of fractures based on the pattern of the brake in underlying conditions a transverse fracture is a horizontal break across the bone typically resulting from a direct blow or stress applied perpendicular to the Bone an oblique fracture is a diagonal break across the bone usually occurring when a force is applied at an angle a spiral fracture is a fracture that spirals around the bone often caused by a twisting or rotational force a communed fracture is a break where the bone is shattered into multiple fragments typically the result of high energy trauma such as car accidents a green stick fracture is a type of incomplete fracture where the bone bends and cracks but is not completely break it's most commonly seen in children due to their softer bones an incomplete fracture is a fracture in which the bone cracks but does not break all the way through a pathologic fracture occurs in Bones weakened by an underlying disease such as osteoporosis or cancer and an epical fracture involves the growth plate in Children and adolescents which can affect bone growth if not treated properly.",
        "Signs and Symptoms of Fractures": "Fractures present with a variety of signs and symptoms that help with the identification and assessment of the injury common findings include deformity where the affected area appears misshapen due to the misalignment of bone fragments and shortening of the LM when a fracture causes a loss of bone length swelling and bruising are often present due to the associated soft tissue damage with ecosis further indicating underlying trauma tenderness and pain are expected at the fracture site with the patient often exhibiting guarding an instinctive movement to protect the injured area crepitus a grading sensation felt over the the broken bone ends may also be detected during palpation false motion can occur where movement is observed at a location in the limb where no joint exists indicating a break in bone continuity in cases of a locked joint movement becomes difficult and painful due to injury near or within the joint in open fractures exposed bone ends may be visible through the break in the skin further complicating the injury with the risk of infection.",
        "Dislocations and Subluxations": "A dislocation occurs when a bone is completely displaced from its joint typically resulting from forces that push a body part Beyond its normal range of motion in some cases the dislocated Joint May spontaneously undergo reduction meaning it returns to its normal position before assessment can begin a partial dislocation of a joint is referred to as a subluxation where the bone is not fully displaced but simply misaligned the signs and symptoms of a dislocation include a marked deformity to the joint swelling and significant pain that worsens with any attempt to move the affected area The Joint may be tender upon palpation and there is usually a complete loss of normal joint function resulting in a locked joint patients may experience exp erien numbness or impaired circulation to the limb or digit due to neurovascular compromis caused by the dislocation this makes dislocations an urgent injury that requires prompt medical attention.",
        "Sprains and Strains": "A sprain occurs when ligaments which connect bones to one another at a joint are stretched or torn typically as a result of a sudden movement that forces the joint Beyond its normal range of motion common signs and symptoms of a sprain include point tenderness swelling ecosis and pain at the S side of injury instability in the affected joint may also be present though sprains rarely involve any noticeable deformity in contrast a strain is an injury to a muscle or tendon caused by violent muscle contraction or excessive stretching strains often result in pain and discomfort though they are usually accompanied by only minor swelling at the injury site both sprains and strains require proper evaluation and management to prevent further damage and promote healing.",
        "Achilles Tendon Rupture": "An Achilles tendon rupture commonly occurs in athletes over the age of 30 particularly those engaged in activities that involve abrupt starts and stops such as basketball tennis or soccer the Achilles tendon which connects the calf muscle to the heel bone is subjected to intense stress during these movements making it vulnerable to injury when this tendon ruptures individuals often describe feeling a sharp pain from heel to calf accompanied by a sudden inability to perform plantar flexation of the foot such as pushing off the ground or standing on their tiptoes acute management of an Achilles tendon rupture follows the rice protocol standing for rest ice compression and elevation along with appropriate pain control this initial treatment aims to reduce inflammation and minimize further damage long-term management varies depending on the severity of the rupture in less severe cases or for non-athletes splinting or casting may allow the tending to heal Over time however for athletes or in cases of a complete tear surgical intervention is often required to repair the tendon and restore full function Rehabilitation including physical therapy is essential in both non-surgical and postsurgical cases to regain strength and flexibility in the affected lag.",
        "Amputations and Initial Management": "Amputations involve the complete separation of a limb or body part from the rest of the body typically resulting from severe trauma such as industrial accidents motor vehicle collisions or combat related injuries inuries due to the nature of the injury amputations often cause significant damage to blood vessels muscles and soft tissues leading to potentially life-threatening Hemorrhage rapid assessment and management of blood loss are critical in preventing shock and further complications immediate medical intervention including the application of a tourniquet direct pressure and wound stabilization are essential to control Hemorrhage and improve the patient chances of survival.",
        "Emergency Care for Musculoskeletal Injuries": "Emergency medical care for muscular skeletal injuries begins with the primary survey focusing on stabilizing the patients Airway breathing and circulation if required perform a rapid full body scan or Target a specific injury depending on the severity of the trauma always follow standard precautions to prevent cross-contamination and remain vigilant for signs of internal bleeding which may not be immediately visible but can be life-threatening in some cases nitrous oxide may be administered for pain relief following local protocols muscular sceletal injuries particularly fractures can lead to significant blood loss due to damage to blood vessels within the bone to address volume deficit interventions such as applying direct pressure to bleeding sites splinting the injured area to minimize further damage and administering IV fluids are crucial this helps to prevent hypotension and the development of an unstable condition when administering fluids use increments of 20 MLS per kg to maintain adequate blood pressure and tissue profusion ensuring the patient remains hemodynamically stable these interventions are critical in preventing complications from muscular skeletal trauma and optimizing patient outcomes.",
        "Cold and Heat Therapy": "In the management of muscular skeletal injuries the application of cold and Heat play a significant role in controlling symptoms and promoting healing cold packs are particularly beneficial during the first 48 Hours following an injury as the cold helps reduce pain and swelling by causing Vaso constriction which limits blood flow to the injured area thereby reducing inflammation additionally cold therapy helps to decrease the release of inflammatory mediators that can exacerbate the injury on the other hand heat therapy should actually be avoided in the first 48 to 72 hours following an injury as it can increase blood flow to the area potentially worsening pain and swelling during this acute phase applying heat too early may lead to further inflammation And Delay the healing process after this initial period heat therapy can be used to help relax muscles and improve circulation but it should only be applied once the risk of increased inflammation has subsided.",
        "Splinting Techniques and Principles": "Splinting is a key intervention for managing fractures dislocations and sprains in prehospital care unless the patient's life is in immediate danger it's important to splint all injuries before moving the patient to minimize further damage reduce pain and prevent complications such as nerve or vascular injury in situations where no formal splinting materials are available alternative methods can be used for example the patient's arm can be secured to the chest wall or an injured leg can be immobilized by binding it to the uninjured leg there are three major types of splint used in the field traction splints which are often applied to stabilize femur fractures rigid splints which provide Firm support to fractured bones and formable splints which are moldable and adaptable to various injury sites in cases involving multiple fractures and critical conditions the most effective method of stabilization is to splint the axial skeleton by using a long backboard with straps or an alternative immobilization device this approach helps secure the entire body limiting movement and reducing the risk of further injury during transport.",
        "Proper Splint Application": "When applying splints it's important to follow established principles to ensure proper immobilization and to prevent complications first remove clothing from the area of any suspected fracture or dislocation to allow for a full assessment assess and document the patient's neurovascular status distal to the injury before and after splinting ensuring that circulation and nerve function are not compromised cover all open wounds with a dry sterile dressing before applying the splint to reduce the risk of infection patients should not be moved until the injured extremity is properly splinted unless of course there's an immediate Hazard to either the patient or responder for fractures the splint should immobilize both the bone ends and the adjacent joints in the case of dislocations the splint should extend along the entire length of the bones above and below the dislocated joint padded rigid splints are necessary here to ensure comfort and prevent further injury manually support the injured site by placing hands above and below the injury in cases where long bone fracture is severely angulated and the extremity lacks of pulse gently apply longitudinal traction to restore circulation however do not attempt to straighten fractures involving joints without first obtaining medical direction if the patient experiences severe pain or is resistant to movement during the application ATT traction discontinue the procedure and splint the injury in the position of the deformity when splinting avoid covering the fingers and toes to allow for ongoing neurovascular assessments cold packs should be applied and the splinted limb should be elevated to minimize swelling suspected spinal injuries should be stabilized in a neutral inline position using a long backboard if the patient exhibits signs of shock align the limb in its normal anatomic position and prioritize transport when in doubt it's always better to splint than to risk further injury by leaving a potential fracture unsplinted improper splint application can lead to several hazards including compression of nerves tissues and blood vessels delayed transport for patients with life-threatening injuries reduced distal circulation aggravation of the exist injury and damage to the surrounding tissue nerves and blood vessels or muscles from excessive movement of the injured bone or joint these risks highlight the importance of careful splinting techniques in emergency care.",
        "Traction Splints": "Traction splints are highly effective for realigning fractures of the shaft of long bones such as the femur these splints work by applying steady gentle traction to the affected limb which helps prevent the broken bone ends from overriding due to unopposed muscle contractions by realigning the bone fragments traction splints can also reduce pain and minimize further soft tissue damage additionally proper traction can help reduce blood loss associated with long bone fractures as it stabilizes the area and limits further injury to surrounding blood vessels however it's important to apply a raction carefully as excessive force can be harmful and lead to complications including further injury to tissues nerves and blood vessels it's crucial to avoid attempting to fully reduce the fracture or force all the bone fragments back into place for perfect alignment as this can cause more harm than benefit the primary goal here is to provide enough traction to prevent further displacement of the fracture and then stabilize the limb for safe trans port to definitive care.",
        "Traction Splint Goals and Contraindications": "The primary goals of inline traction are to stabilize fracture fragments to prevent excessive movement align the injured limb sufficiently so it can be placed in a splint and avoid neurovascular compromise which could lead to permanent damage it's important to use the least amount of force necessary to achieve these objectives traction splints are primarily used for stabiliz izing isolated fractures of the midshaft femur where they are most effective in preventing further injury during transport however traction splints should not be used in certain situations as they may exacerbate injury these contraindications include injuries to the upper extremities fractures close to or involving the knee pelvic injuries partial amputations or avulsions where there is bone separation and injuries involving the lower leg foot or ankle in such cases alternative stabilization methods must be employed to avoid worsening the patient's condition.",
        "Hair and Sager Traction Splints": "The hair traction splint is specifically designed to stabilize fractures of the femur by applying countertraction to the limb this countertraction is achieved through anchoring the splint at two key points the issue or the lower part of the pelvis and the groin by pulling in opposite directions the splint helps to realign the broken femur reducing pain and preventing the bone ends from moving and causing further soft tissue damage this traction helps to alleviate muscle spasms that naturally occur around a fracture and prevents the bone fragments from overriding one another that being said care must be taken to avoid applying excessive pressure on the external genitalia when securing the device as improper positioning can cause additional discomfort and injury to sensitive areas the hair traction splints Effectiveness in providing steady controlled traction make it a preferred tool for field management of femur fractures the Sager traction splint is another type of traction device known for being lightweight Compact and easy to store store making it ideal for prehospital care and transport unlike the hair splint which requires countertraction through anchoring points the Sager splint allows for direct application of a measurable amount of traction that can be adjusted as necessary this measurable traction is beneficial in ensuring the correct amount of force is applied preventing excessive traction that could cause harm the ability to Monitor and adjust the tension applied makes it a versatile option for treating femur fractures in the field its compact design also allows for quicker application and easier storage.",
        "Rigid Splints": "Rigid splints on the other hand are used for a broader range of injuries including fractures dislocations and even severe sprains made from materials like wood metal plastic or fiberglass these flints provide firm stabilization by limiting movement at the injury site these splints are applied to the sides front and or back of the injured limb depending on the type and location of the injury and are secured in place using bandages or straps rigid splints are particularly useful in preventing further displacement of fractured bones reducing pain and protecting nerves blood vessels and the surrounding tissues from additional damage they help maintain the alignment of the injury and are essential for safe patient transport when applied properly rigid splints significantly reduce the risk of complications by immobilizing the injured area while allowing the patient to be transported without exacerbating the injury.",
        "Position of Deformity and Pneumatic Splints": "When splinting a limb it's sometimes necessary to leave the limb in the position of deformity rather than attempting to straighten it this is particularly important in two scenarios when a injury has caused significant misalignment attempting to reposition the limb may cause further damage or pain or if while applying G traction to a fracture of a long bone shaft you encounter resistance or the patient experiences extreme pain it's best to splint the limb in its current position to avoid worsening the injury in these cases padded board splints should be applied to both sides of the limb for stabilization soft roller bandages are used to secure the splints without applying excessive pressure ensuring immobilization while maintaining comfort for dislocations the general rule is to splint The Joint in the position it's found attempting to realign the dislocated joint can cause significant pain and may result in neurovascular damage immobilizing the joint as it's found and securing it for transport is the safest approach in prehospital care pneumatic splints are valuable tools for stabilizing fractures especially those involving the lower leg or forearm they're effective in providing gentle uniform pressure around the injured area helping to control bleeding and reduce swelling however they are not suitable for angulated fractures or fractures involving joints as they cannot provide adequate support for these complex injuries air splints the most commonly used type of pneumatic splint come in a variety of sizes and shapes to accommodate different body parts they must always be inflated after application to ensure proper fitting and stabilization they help control bleeding by applying even pressure to the injury site and reducing swelling making them ideal for many closed fractures that being said they should not be used on open fractures where sharp bone ends are exposed as they could further damage tissues or cause complications before applying an air splint the provider should cover any open wounds with a sterile dressing additionally care must be taken to avoid overinflation as temperature changes can cause the air inside the splint to expand.",
        "Pneumatic Anti-Shock Garments": "Pneumatic anti-shock garments are another type of pneumatic device primarily used for stabilizing suspected pelvic fractures and providing uniform pressure to reduce bleeding these are not recommended for treating shock and have specific contraindications these include pregnancy pulmonary edema acute heart failure penetrating chest injuries groin injuries and major head injuries when using this device for pelvic stabilization all compartments should be inflated and the device should not be removed in the field it's important to document the patient's blood pressure the time of application and The observed results when reported in the patient's condition to the receiving medical personnel.",
        "Formable Splints and Other Devices": "Formable splints are adaptable and can be shaped to fit a variety of injuries making them particular useful in immobilizing fractures dislocations and soft tissue injuries these splints are versatile and provide support without requiring the limb to be in a straight position making them ideal for complex or angulated injuries common types of formable splints include vacuum splints these can be easily molded around a deformed limb by removing air from the splint which makes it rigid this allows for customiz the mobilization of the injured area pillow splints are often used for ankle injuries and offer comfort and support by cradling the injured area in a padded structure structural aluminum malleable splints or Sam splints are lightweight and highly adaptable and can be shaped into various configurations to provide support for fractures or sprains they can be folded and molded to stabilize a wide range of injuries and are often used in field settings for their ease of application the sling and swave is a simple yet effective method for immobilizing shoulder clavicle and upper arm injuries the sling supports the arm while the swave secures it against the chest limiting movement and preventing further injury pelvic binders are used to stabilize pelvic fractures and provide circumferential compression to control bleeding and reduce movement of the fractured pelvis pelvic binders are designed to provide temporary stabilization for suspected pelvic fractures particularly in trauma settings these devices are essential for reducing movement of the fractured pelvis controlling Hemorrhage and minimizing the risk of further injury to internal organs and blood vessels a pelvic binder should be lightweight made of soft material for comfort and even easily applied by a single person to ensure quick and effective stabilization in prehospital care buddy splinting is a simple and effective method for immobilizing injuries involving the fingers or toes this technique involves taping the injured digit to the adjacent uninjured digit which acts as a natural splint providing stability and support this is particularly useful for treating minor fractures spring or dislocations of the figures or toes.",
        "Complications of Musculoskeletal Injuries": "Muscular skeletal injuries can lead to various complications often influenced by factors such as the force that caused the injury the location of the injury and the overall health of the patient the severity of the injury can result in complications that extend beyond the initial trauma requiring careful assessment and management one of the primary concerns with open fractures is the risk of infection to reduce the risk it's important to carefully brush away any debris from the skin surrounding the open fracture before applying a sterile dressing this prevents for materials from entering the wound which could lead to infection and delayed healing a major long-term consequence of muscular skeletal injuries is disability which can greatly impact the patient's quality of life prompt and effective management including pain control and proper stabilization can minimize complications administering analgesia is an essential step to alleviate pain during transport Transportation considerations are vital especially in cases involving compromised circulation a patient with a pulseless limb or suspected compartment syndrome must be given the highest priority for transport if treatment facilities are more than an hour away Air transport or immediate ground transport is recommended to ensure the patient receives Prompt Care in cases where distal circulation of a limb is impaired it's critical to consult with medical direction to determine the appropriate interventions and transport decisions.",
        "Peripheral Nerve and Vascular Injuries": "Peripheral nerve and Vascular injuries are significant concerns following muscular skeletal trauma as they can lead to serious complications if not properly managed when blood vessels are damaged as a result of the injury devascularization may occur cutting off blood supply to the affected area this can lead to esea and tissue death if circulation is not restored in a timely manner in cases where displaced fracture fragments are present these sharp bone ends can lacerate or impale nearby by nerves resulting in nerve damage that can cause loss of sensation or motor function in the affected limb in a similar fashion neurovascular injuries are common following joint dislocations as a dislocation May compress stretch or tear nearby nerves and blood vessels to manage these risks it's essential to consistently assess and reassess pulses distal to the injury site to ensure that there is adequate blood flow additionally controlling bleeding through direct pressure bandaging or tourniquet application when necessary is crucial to prevent excessive blood loss maintaining adequate intravascular volume through fluid resuscitation can help stabilize the patient and prevent shock especially in cases involving significant blood loss from vascular injuries.",
        "Compartment Syndrome": "Compartment syndrome is one of the most serious complications that can arise from a muscular skeletal injury it occurs when increased pressure within a closed muscle compartment compromises circulation and nerve function leading to tissue ischemia and potentially irreversible damage the longer the condition persists the higher the risk of tissue necrosis both external factors such as tight bandages or splints and internal factors such as swelling or bleeding within the compartment can contribute to the development of compartment syndrome open fractures are at particular risk for compartment syndrome as they are often associated with higher energy injuries and can cause significant tissue damage typically compartment syndrome develops within 6 to 12 hours following an injury and it's characterized by severe pain that is often localized to the affected compartment and disproportionate to the injury itself additional signs include skin poar and paresthesia or numbness and tingling in the affected area a late sign would be absence of distal pulses in the involved extremity indicating that blood flow has been severely compromised if a patient has a fracture below the elbow or knee it's important to ask about extreme pain that is not relieved by typical interventions decreased pain sensation indicating potential nerve damage pain on stretching of the affected muscles a Hallmark sign of compartment syndrome and or decreased strength in the affected limb which may suggest early neurovascular compromise management of compartment syndrome should begin with immediate steps to reduce pressure and prevent further complication the affected extremity should be elevated to Heart level which helps to maintain proper circulation without increasing pressure in the compartment ice packs should be applied over the extremity to reduce swelling but care should be taken not to apply them directly to the skin to avoid frostbite any constrictive clothing or splint materials should be loosened or removed to relieve external pressure on the affected area further management includes administering oxygen to maintain tissue oxygenation and supporting circulation with crystalloid Solutions as needed to maintain profusion and prevent shock pain management is critical in compartment syndrome due to the severe pain involved nitrous oxide may be considered for pain relief if permitted by local protocols immediate transport is essential as compart syndrome is a medical emergency that requires surgical intervention to relieve pressure throughout transport it's important to frequently reassess neurovascular status checking for changes in circulation sensation and motor function to detect any worsening of the condition early and aggressive management can help prevent permanent damage to the affected tissues.",
        "Crush Syndrome": "Crush syndrome occurs when an entrapped limb is released after being compressed for an extended period typically 4 to 6 hours or longer during the time of compression rabdom alysis begins to occur where muscle tissue dies and breaks down leading to the release of harmful byproducts such as myoglobin potassium and other intracellular contents into the bloodstream once circulation is restored this sudden release can result in severe complic including kidney failure hyperemia and even cardiac arrest before releasing the compressing Force treatment must be guided by medical direction as several critical steps are required to mitigate the risk of crush syndrome the primary focus is on stabilizing the patient before and during the release of pressure Begin by assessing the ABCs to ensure the patient stable administer supplemental oxygen as needed to maintain proper oxygenation especially considering the potential for respiratory and circulatory compromise consider administering a bolus of crystalloid solution to maintain intravascular volume and support circulation this fluid administration helps to loot the harmful products released into the bloodstream and prevents kidney damage do not apply a compressive device such as a tourniquet to the affected limb as this could worsen the release of toxins and exacerbate the condition some protocols may call for the administration of sodium bicarbonate as a prophylactic medication prior to removing any of the compressive Force please make sure you review your local protocols before administering this medication.",
        "Thromboembolic Disease": "Thromboembolic disease includes conditions such as deep vein thrombosis Dev BT and Pulmonary embolism PE both of which are significant causes of death following trauma or immobilization DVT occurs when a blood clot forms in the Deep veins typically in the legs and can become life-threatening if the clot dislodges and travels to the lungs causing a pulmonary embolism signs and symptoms of DVT include disproportionate swelling of the affected extremity discomfort in the extremity that worsens with movement or use warmth and redness of the extremity due to inflammation when a DVT dislodges it can lead to a pulmonary embolism signs and symptoms of a PE include sudden onset of difficulty breathing puic chest pain which worsens with breathing teyia tacac cardia signs of right-sided heart failure due to increased pressure in the pulmonary circulation and shock Cardiac Arrest can occur if the embolism severely impairs circulation and gas exchange patients with long bone or pelvic fractures are also at risk of developing a fat embolism syndrome this condition occurs when fat droplets from the bone marrow enter the bloodstream and obstruct small blood vessels usually in the lung lungs leading to similar symptoms as a pulmonary embolism field treatment for fat embolism syndrome focuses on maintaining the airway ensuring adequate oxygenation supporting intravascular volume through fluid administration and arranging rapid transport to a medical facility.",
        "Clavicle and Scapula Fractures": "Fractures of the clavicle are among the most common bone injuries particularly in children these fractur often occur when a child Falls onto an outstretched hand transmitting the force of the fall to the clavicle additionally clavicular fractures can result from crushing injuries to the chest a typical presentation involves the patient reporting shoulder pain and holding the arm across the front of the body to immobilize it in younger children pain may be felt throughout the entire arm and they are often unwilling to use the injured limb at all swelling and point tenderness are common at the fracture site and because the clavicle lies just beneath the skin a visible deformity may occur with the skin occasionally tinting over the displaced fracture segment this tinting indicates the proximity of the bone to the skin and increases the risk of an open fracture a significant concern with clavicular fractures is the potential for neurovascular compromise as the fracture may damage nearby nerve in blood vessels careful assessment of distal circulation and nerve function is necessary to ensure no further complications arise from the injury fractures of the scapula are relatively rare due to the Bon's strong protection by surrounding muscles when they do occur it's typically the result of violent direct trauma to the back impacting the area directly over the scapula this type of trauma is often severe and may involve additional injuries to the thoracic cage lungs and even the heart because of the force required to fracture the scapula these injuries often occur in conjunction with other serious conditions such as pneumothorax hemothorax or rib fractures therefore it's essential to carefully assess the patient for signs of these potentially life-threatening conditions conditions including respiratory distress chest pain diminished breath sounds or shock common signs of scapular fractures include abrasions contusions and significant swelling over the affected area the patient will usually exhibit limited arm movement due to the pain and instability caused by the fracture.",
        "Acromioclavicular Joint Injuries": "The acromioclavicular or AC joint is the Junction between the lateral aspect of the clavicle and the Acron process of the scapula this joint is frequently injured in contact sports like football and hockey especially when a player Falls onto the point of their shoulder the impact drives the scapula downward and away from the outer end of the clavicle resulting in a dislocation commonly referred to as an AC separation in cases of AC separation the distal end of the clavicle typically protrudes creating a noticeable deformity the patient will often report pain and point tenderness over the AC joint and may exhibit limited shoulder movement due to discomfort fractures of the clavicle and scapula as well as AC separations can be effectively immobilized using a sling and swave this method helps to support the injured area reduce movement and minim minimize pain during transport and treatment proper immobilization with a sling and SWA is essential for stabilizing the injury and preventing further damage until definitive care can be provided.",
        "Shoulder Dislocations": "The gleno humoral joint where the head of the humoris meets the glenoid fossa of the scapula is the most frequently dislocated large joint in the body this type of dislocation occurs most commonly in in an anterior direction where the humoral head is displaced forward shoulder dislocations are extremely painful impatients will often exhibit guarding instinctively holding the arm close to the body to minimize movement the shoulder joint typically becomes locked in its dislocated position and the overall appearance of the shoulder may look squared off or flattened compared to the normal rounded Contour in an anterior dislocation the humoral head can be felt protruding under the pectoralis major muscle on the front of the chest wall in some cases patients may also experience numbness in the hand which could indicate compression or stretching of nerves or compromised blood circulation due to the dislocation stabilizing an anterior shoulder dislocation can be painful for the patient to manage this first splint The Joint in the position that is most comfortable for the patient if needed use a pillow rolled blankets or towels to fill the space between the arm and chest to provide additional support apply a sling to the forearm and wrist to help support the weight of the arm secure the arm in the sling by attaching it to the pillow and the chest with a swave the dislocation of the shoulder disrupts the supporting ligaments on the anterior aspect of the shoulder dislocations often recur because these ligaments may not heal adequately in some cases patients are able to reduce their own dislocated shoulders that being said a shoulder dislocates posteriorly rather than anteriorly approximately once in every 20 cases in these dislocations the arm is typically locked in an inducted position preventing rotation reduction of a posterior shoulder dislocation usually requires medical supervision.",
        "Humerus Fractures": "Fractures of the humoris can occur in three primary locations proximally in the mid Shaft or distally at the elbow proximal humoral fractures are frequently seen in older adults often resulting from Falls mid shaft fractures are more common in younger patients typically due to high energy trauma when assessing a humoral fracture examine the extremity for significant swelling ecosis gross instability and cidus additionally the radial nerve may be damaged by the initial force or become entrapped within the fracture site with wrist drop being a classic sign of such an injury if the fracture presents with angulation longitudinal traction may be applied to realign the deformity after the extremity is positioned correctly a rigid splint should be applied from the axelia to the elbow in children with humoral fractures be aware of the potential for developing compartment syndrome in the forearm.",
        "Elbow Injuries": "Elbow injuries commonly involve fractures and dislocations and differentiating between the various types of injuries often requires radiographs as they generally produce similar limb deformities and necessitate similar Emergency Care nerve and blood vessel injuries are frequent in elbow trauma when managing elbow injuries periodically assess distal neurovascular function if strong pulses and good capillary refiller present splint the elbow in the position that's found apply two padded board splints to each side of the limb securing them with soft roller bandages you can also mold a padded wire ladder splint or Sam splint to the shape of the limb if the hand is cold and pale or if there's a weak or absent pulse and poor capillary refill this would indicate a potential blood vessel injury consult medical Direction immediately in such cases if if the limb is pulseless and significantly deformed at the elbow apply gentle manual traction along the long axis of the limb to reduce the deformity.",
        "Forearm and Wrist Fractures": "Fractures of the forearm involving the radius and olna are prevalent across all age groups but are most frequently observed in children and older adults these fractures often occur simultaneously when the injury results from a fall onto an outstretched hand an isolated fracture of the olna commonly known as a night stick fracture can result from a direct Blow To The Bone distal radius fractures are referred to as col's fractures characterized by the silver fork deformity which gives the patient's arm a distinctive appearance in children coli fractures may involve the growth plate potentially leading to long-term complications to stabilize fractures of the forearm or wrist use a padded board air vacuum or pillow splint when the fracture involves the shaft of the bone include the elbow joint in the splint however splinting of the elbow is not necessary for fractures near the wrist if feasible Elevate the injured extremity above the heart to help reduce swelling injuries of the wrist and hand require confirmation through radiographs dislocations in this area are typically associated with fractures a common wrist injury is an isolated non-displaced fracture of a carpal bone usually the scaffo hand injuries can vary widely and may have serious consequences therefore all hand injuries should be promptly evaluated by a physician avoid attempting to pop a dislocated finger joint back into place additionally any amputated Parts should be taken to the hospital with the patient do not soak the part in water or allow it to freeze.",
        "Pelvic Fractures": "Fractures of the pelvis are relatively uncommon but can lead to significant mortality in blunt trauma patients primarily due to massive Hemorrhage these in injuries typically result from high energy trauma such as Crush injuries motorcycle crashes or Falls from substantial Heights when a pelvic fracture occurs various internal structures are at risk of injury including the bladder urethra rectum vagina sacral nerve plexus pelvic veins internal and external iliac arteries arteries in the lumbar region and nerves in the lumbar and sacral regions including the sciatic and femoral nerves pelvic fractures can lead to life-threatening blood loss with several liters of blood potentially accumulating in the pelvic and retrop paranal spaces often there are no visible signs of bleeding until severe blood loss has occurred patients with pelvic ring disruptions who have a stable injury may experience pelvic pain and difficulty bearing weight more severe pelvic injuries can present with profound shock which is characterized by significant drop in blood pressure and reduce profusion to vital organs leading to symptoms such as confusion rapid heart rate and shallow breathing gross pelvic instability a Hallmark of severe injury manifests as abnormal movement or misalignment of the pelvic bones which can be detected through physical examination and imaging studies patients may experience diffuse pelvic and lower abdominal pain which often radiates throughout the pelvic region and lower abdomen due to the involvement of multiple structures in possible Associated Hemorrhage in addition to these primary symptoms bruising or lacerations may be observed in areas such as the perineum scrotum groin SU region and flank these signs indicate trauma to the soft tissues and potentially to the underlying organs hematuria or the presence of blood in the urine is another significant finding that suggests injury to the bladder or urethra blood may also be seen coming from the meus of the penis vagina or rectum pointing to possible injuries to these areas or Associated internal bleeding.",
        "Types of Pelvic Ring Disruptions": "Lateral compression pelvic ring disruptions are specifically caused by an impact on the side of the body such as from a sideon collision or a direct blow this type of injury causes the side that sustains the impact to rotate inward around the sacrum disrupting the normal alignment of the pelvic ring these disruptions are often accompanied by injuries to other regions of the body including the abdomen and thorax due to the high energy forces involved the associated trauma can complicate the clinical picture and necessitate a comprehensive assessment and management plan anterior posterior compression pelvic ring disruptions can occur due to head-on motor vehicle collisions motorcycle crashes Falls or when a pedestrian is struck headon by a vehicle in the scenarios the force of impact compresses the pelvis in the anterior to posterior Direction This compression results in tearing of the pubic synthesis and the posterior supporting ligaments as a consequence the pelvis spreads apart and opens in a manner reminiscent of a book resulting in what is termed as an open book pelvic fracture this type of injury carries a significant risk of massive blood loss due due to the disruption of major vascular structures within the pelvis vertical Shear injuries occur when a major force is applied to the pelvis from above or below for instance when Landing from a height the force is transmitted through the legs to the pelvis leading to the complete displacement of one or both sides of the pelvis toward the head patients with vertical Shear injuries are likely to exhibit significant shortening of the limb on the affected side and face a high risk of massive Hemorrhage into the pelvis this displacement and Associated bleeding require prompt and effective management to address the severe implications of such injuries a stradle fracture occurs when an individual Falls and lands on the perineum resulting in bilateral fractures of the inferior and Superior Rami of the pelvis while these fractures do not typically interfere with weight bearing they carry significant risks due to potential Associated complications open pelvic fractures are severe life-threatening injuries characterized by the presence of a laceration in the skin of the pelvic region rectum or vagina these types of fractures are rare and are usually caused by High Velocity trauma which often lead leads to massive Hemorrhage even small amounts of blood detected during a vaginal or rectal examination should raise suspicion of an open fracture given the high risk of significant internal injury and bleeding.",
        "Assessment and Management of Pelvic Fractures": "When managing pelvic fractures suspect such an injury if the patient has sustained a high velocity trauma and reports discomfort in the lower back or abdomen deformity or swelling may not always be visibly apparent so the most reliable indicator is tenderness upon firm compression and palpation to assess for tenderness perform the following steps place the palms of your hands over the lateral aspect of each iliac crest apply firm but gentle inward pressure on the pelvic ring with the patient lying sepine place your palm over the anterior aspect of each iliac crest and apply firm downward pressure use your palm to palpate the pubic symphysis firmly but gently we no longer Rock the pelvis to determine stability if there is an injury to the bladder or urethra you may observe lower abdominal tenderness hematuria or blood in the urethal opening conduct a primary survey to evaluate the patient's overall condition treatment should focus on monitoring the airway breathing and circulation ensuring spinal immobilization and establishing IV access with at least one large bore catheter management aims to reduce bleeding and address pelvic instability to stabilize the patient's condition methods of stabilization for pelvic fractures include the application of a Pneumatic anti-shock garment a pelvic bind or tying a sheet around the pelvis once the patient is immobilized on a long backboard they should be transported rapidly to a Trauma Center during transport administer IV fluids to maintain adequate tissue profusion as evidenced by radial pulses it's important to avoid inducing hypertension which could exacerbate bleeding or other complications.",
        "Hip Dislocations": "Dislocations of the hip typically occur only after significant trauma nearly all hip dislocations are posterior where the femoral head is displaced in a posterior fashion into the muscles of the buttock a hip dislocation should be suspected in patients who have experienced a motor vehicle collision and present with contusions lacerations or obvious fractures to the knee region anterior dislocation of the for Moree head is rare when it occurs the legs are often spread wide apart and locked into this position posterior hip dislocations are frequently associated with injury to the sciatic nerve when the femoral head is displaced from the hip socket it can cause partial or complete paralysis of the sciatic nerve typically affecting only the dorsal flexors this results in a condition known commonly as foot drop patients with a posterior hip dislocation typically present with the hip joint flexed and the thigh rotated inward toward the midline of the body this position often causes the affected thigh to rest on top of the opposite thigh the flexation and internal rotation result from the displacement of the fal head posterior ly which disrupts the normal alignment of the hip joint and surrounding structures distinctive signs of a posterior hip dislocation include severe pain localized to the hip region which is often intense and sharp the patient will usually exhibit strong resistance to any attempt to move the joint as movement exacerbates the pain and may further damage the surrounding tissues palpation of the lateral and posterior aspects of the hip region typically reveals tenderness indicating inflammation and injury in these areas to assess for sciatic nerve injury evaluate both sensation and motor function in the lower extremity this involves checking for sensory deficits such as numbness or altered sensation and motor deficits including weakness or loss of movement in the leg the sciatic nerve which runs posteriorly to the hip joint can be damaged by the displaced femoral head leading to symptoms such as weakness in the dorsa flexors of the foot commonly referred to as foot drop do not attempt to reduce a dislocated hip on the scene instead keep the hip in the position it's found without manipulating or attempting to reduce the location place the patient aine on a scoop stretcher or a long backboard to ensure stability and prevent further injury support the affected limb with pillows and rolled blankets to maintain proper alignment and comfort secure the entire limb to the backboard using long straps to prevent any movement of the hip region during transport ensure prompt transport of the patient to a medical facility for further evaluation and treatment as the dislocation requires Professional Management.",
        "Proximal Femur Fractures": "Fractures of the proximal femur are a prevalent injury particularly among older adults and are commonly referred to as hip fractures despite this common nomenclature these fractures don't typically involve the hip joint directly instead they occur in various locations around the femoral head and neck and can be classified into several types based on their location femur neck fractures occur in the narrow region just below the femoral head which is the area that connects the head of the femur to the shaft they can be intracapsular occurring within the hip joint capsule or extracapsular occurring Outside The Joint capsule inter trantric fractures occur in the middle region of the femur between the greater and lesser trochanter this area is characterized by the prominence of the femoral tranters which serve as attachment points for muscles that stabilize the hip joint sub trochanteric fractures occur below the trochanter in the proximal shaft of the femur these are often associated with high energy trauma but can also occur in individuals with weakened bones due to osteoporosis osteop partic bones are more susceptible to fractures from minor Falls or injuries however proximal femur fractures can also result from high energy trauma in younger adults such as from severe accidents or Falls from significant Heights the management of these fractures typically involves a combination of surgical intervention to realign and stabilize the bone and Rehabilitation to restore function and Mobility given the significant impact these fractures can have on an individual's mobility and quality of life timely and effective treatment is crucial patients with proximal femur fractures often display a very characteristic deformity the affected leg is typically externally rotated and appears shorter than the uninjured leg patients usually experience an inability to walk or move the injured leg and the hip region is tendered to palpation gentle rolling of the leg May elicit pain but is unlikely to cause further damage occasionally pain may be referred to the knee assessment should include evaluating the pelvis for any soft tissue injury and applying appropriate bandages if needed it's important to check for pulses and assess motor and sensory functions in the lower extremity once the initial assessment is complete splint the lower extremity to stabilize the fracture the method of splinting should be based on the patient's age and severity of the injury all patients with proximal femur fractures may experience significant blood loss administer oxygen as needed monitor Vital Signs frequently and remain vigilant for signs of shock.",
        "Femoral Shaft Fractures": "Femoral shaft fractures can occur at any location along the shaft of the femur following the fracture the quadricep muscles often go into spasm which can produce significant deformity of the limb this muscle spasm typically results in noticeable shortening of the affected limb occasionally these fractures are open with fragments of bone protruding through the skin such injuries frequently involve significant blood loss any open wounds should be covered with a dry sterile dressing to minimize the risk of infection and control bleeding if signs of impaired circulation are present in the foot or leg below the level of the fracture apply gentle longitudinal Traction in line with the limb's long axis gradually realign the leg from its deform position to restore overall limb alignment monitor the patient for signs of shock ensure full spinal immobilization and establish vascular access stabilize the injured extremity by placing it in a traction splint or using a Pneumatic anti-shock garment.",
        "Knee Injuries": "Knee injuries cover a range of conditions including ligament injuries dislocated patella and fractures each type of injury requires a thorough assessment to determine the extent of damage in appropriate management to evaluate a knee injury effectively carefully inspect the patient's need for key indicators such as swelling deformity or tenderness ligament injuries are prevalent among both recreational and competitive athletes due to the high stress nature of sports activities the knee joint is stabilized by several crucial Li movements and injuries often occur as a result of sudden movements such as twisting or turning or from direct impacts the medial collateral ligament or MCL and the lateral collateral ligament LCL are particularly susceptible to injury MCL injuries are especially common often resulting from lateral forces that push the knee inward these can lead to significant pain instability and functional impairment of the knee symptoms may include swelling bruising and difficulty bearing weight on the affected leg the patella or kneecap can become dislocated due to trauma or sudden changes in Direction a dislocated patella is typically characterized by a visible shift in the position of the patella often causing pain and difficulty in knee movement fractures around the knee can involve the patella FEMA or tibia and may result from direct trauma or Falls these fractures can cause severe pain swelling and potentially visible deformities prompt and accurate assessment of knee injuries is essential to determine the appropriate treatment and prevent further complications immediate care may include immobilization of the knee application of ice to reduce swelling and elevation of the leg follow-up care often involves Imaging studies such as x-rays or MRI to confirm the diagnosis and guide the treatment plan.",
        "Knee Dislocations": "Dislocation of the knee is a severe injury that may involve damage or tearing of the surrounding ligaments when evaluating a suspected need dislocation carefully assess distal circulation particularly if the patient exhibits gross deformity severe pain and an inability to move the joint if distal pulses are absent it's imperative to contact medical Direction immediately for instructions on further stabilization and intervention the direction of the dislocation describes the position of the tibia relative to the femur common types of knee dislocations will include posterior dislocations that occur when a direct blow to the knee forces the tibia to shift posteriorly relative to the femur this type of location often results in damage to the anterior and posterior ligaments also medial dislocations which result from a direct blow to the lateral part of the leg causing the tiia to shift meally patients with medial dislocations typically report significant pain and describe the knee as having given out in cases where adequate distal pulses are present splint the knee in the position it was found and transport the patient properly do not attempt to manipulate or straighten the injured knee if distal pulses are present however if the limb is pulseless medical Direction May instruct you to realign the deform limb in such cases you should only make one attempt to realign following precise instructions for medical Direction.",
        "Fractures Around the Knee": "Fractures around the knee can occur at various sites including the distal end of the femur the proximal end of the tibia or within the patella differentiating between these fractures and ligament injuries can be challenging as non-displaced or minimally displaced fractures might closely resemble ligament damage in contrast displacing fractures often present present with significant deformity which may be mistaken for a dislocated joint when managing a fracture around the knee if the patient maintains a good distal pulse splint the extremity in the position in which it was found in order to avoid further injury Elevate the leg to Heart level and apply cold packs to help reduce swelling and pain continuously monitor the distal neurovascular function while transporting to patient to the hospital to ensure there is no deterioration in circulation or sensation.",
        "Patella Dislocations": "Dislocation of the patella is a frequent injury among teenagers and young adults involved in athletic activities or even minor twisting motions can result in dislocation when the patella dislocates it typically shifts to the lateral side of the knee causing the knee to be held in a slightly flexed position this displacement creates a noticeable deformity to manage this injury splint the knee in the position it's found immobilize The Joint by applying a padded board splint to both the medial and lateral aspects of the knee in some cases as you apply the splint the patella May spontaneously return to its normal position however providers should ensure proper splinting to prevent further displacement and stabilize the KN during transport to a medical facility.",
        "Tibia and Fibula Fractures": "Injuries to the tibia and fibula can occur anywhere along the shaft of these bones between the knee joint and the ankle joint it is common for both bones to fracture simultaneously and such fractures can result in significant deformity including marked angulation or rotation open fractures of the tibia are particularly prevalent where bone fragments May protrude through the skin to manage a tibia or fibula fracture use a padded rigid long leg splint or an air splint extending from the foot to the upper thigh secure the affected leg to the opposite leg to stabilize it prior to applying the splint correct any severe deformity by applying gentle longitudinal traction to realign the limb into a position suitable for splinting in some cases tibia and fibula fractures are associated with vascular injury realigning the limb during initial management May restore adequate blood supply to the foot improving circulation and potentially mitigating further complications.",
        "Ankle Fractures": "Ankle fractures typically result from Sudden and forceful movements of the foot such movements transmit an axial load through the foot causing the Talis to impact the distal tibia and leading to a fracture the primary signs and symptoms of an ankle fracture include pain deformity and swelling to manage an ankle fracture use a commercially available splint or pillow splint to stabilize the injury ensure that the toes remain exposed to allow for frequent monitoring of distal neurovascular function Elevate the injured extremity to Heart level and apply cold packs to help reduce swelling and alleviate pain to manage a fractured dislocation of the ankle Begin by focusing on relaxing the calf muscle this is achieved by flexing the patient's leg at the knee which helps reduce muscle tension and allows for more mobility of the foot with the muscle relaxed carefully attempt to rotate the foot back back into its normal anatomical position it is important to perform this maneuver gently to avoid causing additional damage or exacerbating the injury after successfully repositioning the foot assess the distal neurovascular status to ensure that circulation sensation and motor function are intact this step is crucial to confirm that realignment has not compromised blood flow or nerve function once neurovascular status is confirmed to be stable apply a split to the ankle securing it to the reduced position to maintain proper alignment and stability if the fracture dislocation cannot be reduced immediately contact medical direction for further guidance on how to proceed in such instances splint the ankle in the position it was originally found to avoid further complications.",
        "Foot Injuries": "Foot injuries frequently involve fractures of the tarsals metatarsals or fanges among these fractures of the toes are particularly common often resulting from direct trauma such as stubbing crushing or impact injuries the tarsel bones including the calcinus are also susceptible to fractures with the calcinus being the most frequently affected this typically occurs when a patient falls or jumps from a height and lands directly on the heel the calanus is particularly vulnerable to injury due to its role in bearing and distributing the weight of the body when the force of the impact is transmitted through the heel it compresses the calcinus this compression results in immediate swelling and ecosis in the area surrounding the heel and the patient may experience severe pain and difficulty in bearing weight in such cases the severity of the injury can be assessed by evaluating the extent of swelling pain and any visible deformities immediate management involves stabilizing the foot with appropriate splints evaluating the extremity to reduce swelling and applying cold packs it's essential to monitor the patient's ability to move the toes and check for signs of neurovascular compromise such as changes in sensation or circulation foot injuries can sometimes have broader implications beyond the immediate area of impact when the force of the injury is transmitted up the legs it can affect the lumbar spine potentially resulting in lumbar spine fractures this connection underscores the need to assess not only the foot but also the surrounding structures when dealing with foot injuries if a dislocation of the foot is is suspected the provider should assess the patient's pulses motor function and sensory function immediately as this evaluation helps determine if there's any compromise to the vascular or neurological systems that could result from the injury foot injuries often present with significant swelling but may not always show gross deformity however even without visible deformity it's essential to monitor the area closely for Chang changes in appearance or function vascular injuries are relatively uncommon in foot injuries but lacerations to the ankle and foot can be concerning these lacerations have the potential to damage important underlying nerves and tendons which may result in functional impairment if not addressed promly puncture wounds in the foot are also common and carry the risk of serious infection if not treated early these wounds can inter ruce pathogens deep into the tissues making early intervention and proper wound care critical to prevent complications to properly splint a foot injury first apply a rigid petted board air splint or pillow splint to the affected area ensure that the splint adequately supports the foot while leaving the toes exposed this exposure is important for ongoing assessment of neurovascular function allowing you to monitor for changes in blood flow and nerve activity when transporting the patient place them in the suine position as this facilitates the elevation of the injured limb helping to reduce swelling and promote better blood circulation proper positioning and splinting are essential to minimize discomfort and prevent further injury during transport.",
        "Amputation Management": "In cases of amputation managing the injury and preserving the amputated part are critical to improving outcomes for partial amputations immobilize the injured part using bulky compression dressings and a splint to prevent further damage avoid severing any partially amputated Parts as this can complicate future reattachment efforts severe and potentially life-threatening Hemorrhage is common with amputations control any bleeding immediately and treat for shock if bleeding can't be controlled with direct pressure apply a tourniquet just above the site of amputation to preserve an amputated part wrap it in a sterile dressing and place it in a plastic bag follow local protocols for preservation the plastic bag should be placed in a cool container filled with ice ensuring the bag floats on a bed of ice water rather than being packed directly in ice keep the amputated part cool but avoid freezing it as frostbite can occur do not attempt to warm or submerge an amputated part in water as this can cause additional damage ensure rapid transportation to an appropriate medical facility and notify the emergency department in advance about the case type and estimated time of arrival for significant blood loss or hypotension administer a Bolis of isotonic crystalloid solution additionally be aware that the patient may experience significant emotional distress which can lead to psychogenic shock address these psychological needs as part of the overall care.",
        "Management of Sprains and Strains": "The management of sprains and strains involves approaches similar to those for fractures focusing on alleviating pain reducing swelling and preventing further injury Begin by allowing the injured area to rest and avoid its use to prevent exacerbation immobilize or splint the injured area to stabilize it and minimize movement which helps in reducing pain and prevents additional harm apply ice or a cold pack to the injury site for 15 to 20 minutes every hour during the first 48 hours to reduce swelling and numb the area use an elastic bandage to apply compression around the injury which controls swelling and provides support Elevate the injured area above the level of the heart whenever possible to promote Venus return and further reduce swelling splinting may be necessary to keep the area stable and supported minimize weight bearing on the affected limmer joint using crutches or brace if needed to protect the injury and facilitate healing manage pain through appropriate medications or other methods as advised with over-the-counter pain relievers like ibuprofen and acetaminophen being commonly used to alleviate discomfort these measures aim to reduce symptoms promote recovery and prevent further complications associated with sprains and strains.",
        "Conclusion and Summary": "This lecture on Orthopedic injuries emphasized the importance of muscular skeletal injuries in clinical practice these injuries are frequently characterized by pain swelling and deformity making them relatively easy to identify however initial assessment should not focus solely on the injury the ABCDE approach assessing for ex zangu Hemorrhage Airway patency breathing circulation disability and exposure is vital to ensure no life-threatening conditions are overlooked early recognition and management of muscular skeletal injuries are essential to prevent long-term disability and impairment we reviewed the muscular skeletal systems anatomy and physiology the system provides the body shape allows movement and protects internal organs movement is produced when muscle contraction generates Force which is transmitted to Bones across joints the system also serves critical roles in a hematopoesis the process of blood cell formation and Vascular Supply which ensures muscles receive adequate oxygen and nutrients understanding these fundamental structures and functions is key to diagnosing and managing injuries lastly we discussed fractures and dislocations fractures are classified as opened or closed with various patterns such as transverse oblique spiral and communed dislocations often caused by trauma result in the displacement of Bones from joints requiring careful assessment and intervention to prevent further damage Emergency Care principles include immobilization splinting and addressing any neurovascular compromise to optimize outcomes for the patient"
    },
    {
        "Introduction to Bleeding": "chapter 27 bleeding bleeding is a condition that requires immediate attention as it can rapidly compromise the patient stability Hemorrhage can present either externally where it's visible and easier to detect or internally where it may be concealed and harder to identify both forms can lead to significant physiological impacts bleeding can result in weakness due to decreased oxygen delivery and tissue profusion it's also a common cause of shock ranking as the second leading cause following myocardial infarction in severe cases uncontrolled bleeding can ultimately lead to death if not addressed promptly.",
        "Understanding Perfusion and Shock": "Profusion refers to the process by which blood circulates within an organ or tissue delivering oxygen and nutrients in sufficient quantities to meet the cell's current metabolic demands while also facilitating the removal of waste products the autonomic nervous system regulates profusion by continuously monitoring the body's needs and adjusting blood flow accordingly hypo profusion commonly known as shock occurs when the cardiovascular system is unable to maintain adequate circulation to ensure that every part of the body can perform its physiological functions this can result in impaired cellular function and lead to systemic organ failure if not corrected.",
        "Emergency Medical Care": "Emergency medical care is structured to provide support for the body's vital organs key organs that require immediate stabilization include the heart which maintains circulation the brain and spinal cord which control and coordinate body functions the lungs responsible for gas exchange and the kidneys which filter waste and regulate fluid and electrolyte balance the focus of prehospital care is to stabilize these systems to prevent further deterioration and to preserve life until more definitive care can be administered.",
        "The Cardiac Cycle": "The cardiac cycle refers to the repetitive process of the heart's pumping action it begins with the onset of contraction of the cardiac muscle and concludes just before the next contraction begins two key factors influencing this process are preload and afterload preload refers to the volume of blood returned to the heart which is available to be pumped out during each contraction after load on the other hand represents the resistance in the aorta or peripheral vasculature that the left ventricle must overcome to eject blood into the systemic circulation both preload and afterload are critical in determining the efficiency and workload of the Heart during each cardiac cycle stroke volume refers to the amount of blood ejected by the Heart during each contraction this Factor along with the heart rate plays a crucial role in determining cardiac output which directly influences blood pressure the cardiac Cycle's efficiency is closely related to the body's ability to maintain proper profusion particularly during instances of bleeding or shock adequate oxygen delivery to tissues depends on several factors including heart rate stroke volume hemoglobin levels and arterial oxygen saturation any compromise in these variables whether due to Hemorrhage poor cardiac output or impaired oxygen carrying capacity can significantly affect tissue profusion leading to hypoxia.",
        "External vs Internal Hemorrhage": "Hemorrhage refers to the discharge of blood from blood vessels which can vary in severity from a minor capillary leak to a significant arterial bleed or blood spurts from The Vessel due to high pressure external bleeding is often more straightforward to manage than internal bleeding as it's visible and can be controlled through several techniques the application of direct even pressure to the wound is the first step in controlling bleeding pressure dressings splints hematic dressings and tourniquets can be used if simple pressure is insufficient in some cases the pressure bandage can help maintain constant pressure over a wound to achieve hemostasis and prevent further blood loss external hemorrhaging typically occurs due to a break in the skin which can expose underlying blood vessels and result in blood loss the severity of the Hemorrhage is often determined by the nature of the wound and the specific blood vessels involved injuries to larger vessels such as arteries tend to cause more significant bleeding compared to injuries to capillaries or veins internal hemorrhaging can occur in any region of the body and is often more difficult to detect than external bleeding as it's simply not visible non-traumatic internal hemorrhage typically arises from medical conditions such as GI bleeding rupture to topic pregnancies or the rupture of aneurysms these types of internal bleeds can rapidly become life-threatening due to the hidden nature of the blood loss making early recognition and intervention critical to Patient outcomes.",
        "Mechanisms of Injury and Assessment": "Mechanisms of injury such as high energy events should raise the index of Suspicion for significant internal injuries even if they are not immediately visible common high energy mois include Falls blast injuries and motor vehicle or motorcycle crashes when assessing a patient use the Decap btls ponic to look for deformities contusions abrasions punctures Burns tenderness lacerations and swelling over the chest and abdomen these findings can indicate external signs of trauma but internal bleeding should also be suspected in patients with penetrating injuries or blunt force trauma non-traumatic causes of internal bleeding include GI bleeding from ulcers or the colon rupture to topic pregnancies and aneurysms in elderly patients symptoms such as dizziness fainting or weakness may be the initial indicators of internal bleeding as they may not always present with typical signs of trauma signs and symptoms of internal bleeding include pain swelling at the sight of hemorrhage distension and bruising additional signs of systemic involvement may include dnia teoc cardia and hypoten attention hematomas as well as specific manifestations such as hemat Uria hematemesis Hema typis Molina and hmates Dia can be present physical signs like tenderness bruising guarding or swelling May indicate underlying trauma and Associated findings such as broken ribs or a rigid distended abdomen further support the suspicion of internal Hemorrhage the first indication of hypmic shock is often a change in mental status and signs of hypo profusion pointing to internal bleeding include an altered level of Consciousness tacac cardia and symptoms such as weakness dizziness or fainting other indicators include thirst nausea vomiting clamy skin shallow and Rapid breathing dull eyes slow reacting pupils and delayed capillary refill in infants and children a weak rapid pulse followed by decreasing blood pressure is actually a late sign signaling Advanced internal hemorrhage significant changes in Vital Signs occur once approximately 2 pints or one liter of blood have been lost hemorrhagic shock arises when blood volume drops too low to sustain adequate profusion potentially leading to death if untreated bleeding should be considered serious in the presence of significant mechanisms of injury particularly when the forces involved are likely impacted by the chest abdomen or both other indicators of serious bleeding include poor General appearance symptoms of shock large amounts of blood loss rapid bleeding or bleeding it cannot be controlled.",
        "Physiological Response to Hemorrhaging": "The body's physiological response to hemorrhaging involves mechanisms designed to control and stop the bleeding typically bleeding ceases quickly due to internal clotting processes and exposure of the blood to air hemostasis is achieved through the aggregation of platelets at the sight of injury forming a plug that seals the damaged vessel however certain medications particularly anti-coagulants can interfere with the body's ability to clot normally prolonging bleeding in patients with hemophilia where the clotting ability is compromised immediate transport to a medical facility is necessary for an appropriate intervention the trauma Triad of death refers to the combination of hypothermia coagulopathy and acidosis which significantly increases the mortality rate in trauma patients hypothermia reduces the body's ability to clot leading to coagulopathy which can exacerbate Hemorrhage acidosis develops as the body struggles to maintain normal cellular function due to inadequate oxygen delivery further complicating the patient's condition recognizing these conditions early and intervening were possible such as rewarming the patient managing bleeding and addressing metabolic acidosis is critical to improving patient outcomes in trauma care for more information on the trauma Triad of death refer to chapter 26.",
        "Emergency Care for External Hemorrhaging": "Emergency medical care for external hemorrhaging involves several key interventions First Direct pressure should be applied to the wound often in combination with pressure dressings and splints if bleeding occurs in an extremity and cannot be controlled using these methods aicet is the preferred option to prevent further blood loss additionally providing high flow oxygen is essential to support oxygenation and ventilation assistance may be necessary depending on the patient's respiratory status direct pressure is the most effective and straightforward method for controlling external bleeding in most cases begin by applying pressure with a gloved fingertip or hand directly over the side of bleeding using a sterile dressing as a barrier to reinforce this a pressure dressing can be created by firmly wrapping a sterile self-adhering roller bandage around the entire wound ensuring coverage both above and below the injury the bandage should be stretch tightly to maintain pressure and control the bleeding and it is important to check for a distal pults after application to ensure circulation is not compromised if direct pressure alone is insufficient to stop the bleeding consider applying a tourniquet or packing the wound with a hemostatic agent wound packing involves creating internal pressure by tightly filling the wound cavity with Galls applying pressure from within to perform this Begin by taking the standard initial steps to to control the bleeding push Galls into the wound with an index finger ensuring it completely and tightly packs the entire wound cavity once packed hold firm manual pressure on the wound for at least 3 minutes or secure it with a snug pressure dressing this technique helps absorb liquid from the blood and concentrates clotting factors promoting hemostasis hemostatic agents are designed to enhance clot formation at the the wound site these agents adhere to damage tissue and either dehydrate the blood or initiate a chemical reaction that stimulates the body's natural quading Cascade after applying a hematic agent it should be able to withstand the high pressure or flow from a bleeding wound cause minimal tissue damage and be easily removed Additionally the agent should not disperse into the body as small particles that could cause complications.",
        "Use of Tourniquets and Splints": "Tourniquets are particularly useful for controlling severe Hemorrhage from an extremity when other methods such as direct pressure have failed they are applied to injuries below the Axia or groin and work by completely stopping blood flow to the injured area there are several commercially available tourniquets including the combat applic tourniquet or cat the Special Operations forces tactical tourniquet or soft T the ratcheting medical tourniquet or rmt and the stretch wrap and Tuck tourniquet or the SWAT T proper application is critical for Effectiveness and it's important to follow the specific steps for each type please keep in mind tourniquets are only meant to be used on extremities please do not place a tourniquet on the patient's neck to stop bleeding of the head before you ask yourself is it necessary that he tells us this remember that there are people who don't understand that McDonald's coffee is hot this figure displays four types of commercially available tourniquets figure a shows the cat tourniquet fig figure B illustrates the soft T figure C shows the rmt and figure D presents the stretch wrap and Tuck tourniquet or SWAT T if a commercial tourniquet is unavailable a makeshift one can be created using a triangular bandage and a stick the bandage should be folded wrapped around the extremity and secured with a knot a stick is in placed over the knot twisting until bleeding stops and distal pulses disappear and then secured in place Mark TK and the time of application on the patient's forehead and inform Hospital staff for uial or axillary Hemorrhage a junctional tourniquet is used ensure the tourniquet is placed proximal to the injury use a wide bandage avoid void narrow materials like ropes or belts and do not cover or loosen the tourniquet once applied in L of a stick you can use a hard suction catheter splints are useful in controlling bleeding and stabilizing injuries air splints can help manage bleeding from severe soft tissue injuries while rigid splints stabilize fractures reduce pain and prevent further soft tissue damage traction splints are specifically used to stabilize isolated femur fractures after applying any splint it's important to monitor circulation in the distal extremity to ensure proper blood flow is maintained.",
        "Managing Nose, Ear, and Mouth Bleeds": "The pneumatic anti-shock garment or passage is an inflatable device that covers the legs and abdomen used to stabilize patients with suspected internal bleeding or shock its use is rare and typically dictated by local protocols so make sure you follow your specific guidelines when considering the application hemorrhaging from the nose ears or mouth can result from various causes including skull fractures facial injuries sinus infections high blood pressure coagulation disorders or even digital trauma nose picking epist AIS or nose beds are common and can lead to significant blood loss potentially resulting in shock to manage a nose bleed apply cold compress to the bridge of the nose while the patient leads forward or place rolled Galls under the upper lip to help control bleeding if bleeding from the nose or ears follows a head injury this could indicate a skull fracture in such cases cover the site with sterile Galls and apply light compression by Loosely wrapping the dressing around the head.",
        "Internal Hemorrhaging and Shock Management": "For internal hemorrhaging definitive care involves rapid transport to the emergency department with treatment focusing on managing shock minimizing movement and quick transport in the Ed ultrasonography may be used to locate internal bleeding in managing hemorrhagic shock the priori is to address exanguination Hemorrhage Begin by taking standard precautions and ensuring the scene is safe identify and stop any major bleeding while quickly evaluating the patient's hemodynamic status establish and maintain an open Airway to ensure proper oxygenation during transport insert at least one preferably two 18 gauge peripheral IVs to prepare for fluid resus itation if transport is delayed obtain IV access at the scene and administer warm isotonic crystalloids such as normal saline and 250 ml increments these patients should not be given anything by mouth continuously monitor the patient level of Consciousness pulse and blood pressure to assess their status and response to treatment.",
        "Differentiating and Treating Bleeding Types": "In managing bleeding and Hemorrhage it's important to first differentiate between external and internal bleeding external bleeding can often be controlled using direct pressure pressure dressings or splints in cases where these methods are ineffective tourniquets should be applied different types of tourniquets such as the cat or makeshift tourniquets can be used depending on the situation hemostatic agents and ballon packing can also help in situations where bleeding is difficult to control it's essential to apply these techniques correctly to stop blood loss while maintaining circulation distal to the injury for internal hemorrhaging rapid transport to the emergency department is critical treatment will focus on managing shock limiting movement and using tools like ultrasonography to locate the bleeding in the the Ed while on scene iv access should be established using an 18 gauge catheter and fluids like normal saline or lactated ringers should be administered in 250 ml increments IO access is an alternative when IV access is difficult keeping the patient warm and monitoring their Vital Signs throughout transport is also vital these steps are aimed at stabilizing the patient and preventing further complications before definitive care is reached in the case of hemorrhagic shock the priority is to stop exanguination manage Airway patency and monitor the patient's hemodynamic status if transport is delayed obtaining IV access on scene becomes necessary administering warm isotonic fluids and avoiding oral intake are key to managing fluid loss and preventing further deterioration monitoring changes in Consciousness pulse and blood pressure provides essential data to guide treatment follow your local protocols and employ tools like tourniquet and splints effectively to prevent shock from worsening and to help improve patient outcomes"
    },
    {
        "Introduction to the Nervous System": "Chapter 30 head and spine injuries the nervous system is a complex and intricate network of nerve cells or neurons responsible for enabling communication and coordination between various parts of the body allowing them to function properly it's composed of three main components the brain which serves as the central control center the spinal cord which acts as the primary conduit for transmitting signals between the brain and the body and the peripheral nervous system which extends Beyond the brain and spinal cord connecting the central nervous system to the limbs and organs these elements work together to regulate body functions control voluntary and involuntary actions and process sensory information head trauma encompasses both head injuries and traumatic brain injuries or tbis with head injury specifically referring to trauma to the head that may involve the scalp skull skull or cranial structures excluding the face the terms head injury and traumatic brain injury are often used interchangeably in clinical practice tbii refers to an injury to the brain that results from an external Force which can lead to a wide range of neurological impairments spinal cord injury or SCI can also have profound consequences often leading to permanent neurological iCal deficits traumatic brain injury in particular is leading cause of both death and long-term disability highlighting the significant impact these injuries have on patient outcomes.",
        "Anatomy of the Nervous System": "The nervous system is anatomically and functionally divided into two major components the central nervous system or CNS and the peripheral nervous system or pns the CNS consists of the brain and spinal cord which serve as the main processing centers for the body's activities the pns on the other hand is responsible for conducting sensory and motor impulses between the skin muscles organs and the CNS these signals allow the body to perform both voluntary and involuntary actions voluntary activities are those that are consciously controlled such as moving muscles while involuntary activities occur without conscious thought such as heart rate regulation and digestion this division ensures the body can efficiently respond to both external stimuli and internal physiological needs.",
        "Structure of the Scalp and Skull": "The scalp is composed of multiple layers with the subcutaneous tissue containing the primary blood vessels that supply it when the vessels are compromised such as in the case of laceration significant Hemorrhage can occur due to the rich vascular Supply the skull consists of the cranium and facial bones with the mandible being the only movable facial bone the cranium houses the brain and is occupied by Approximately 80% brain tissue 10% blood and 10% cerebral spinal fluid all of which play a role in maintaining brain function and protecting it from injury the brain connects to the spinal cord through a large opening at the base of the skull known as the framan Magnum allowing the central nervous system to remain continuous the cranium is formed by four major Bones the oxop put at the posterior base of the skull the temporal regions located on each side near the temples the parietal regions which span the top and sides of the skull and the frontal region which forms the forehead these bones provide structural protection for the brain while allowing for the attachment of muscles and other tissues.",
        "Facial Bones and Their Functions": "The face is composed of 14 bones with the primary ones being the maxill which form the upper jaw the zygomas also known as the cheekbones and the mandible the only movable facial bone that forms the lower jaw the orbit or eye socket is constructed from the frontal bone and two facial bones providing a protective enclosure for the eyes the nose is primarily made up of flexible cartilage allowing for its mobility and structural resilience these facial structures not only protect vital sensory organs but also play roles in functions such as as eating breathing and communication.",
        "Anatomy of the Spine": "The spine consists of 33 vertebrae that provide structural support and protect the spinal cord these vertebrae are stabilized by ligaments joint capsules and muscles which work together to maintain the Integrity of the axial skeleton and allow for movement the vertebrae are classified according to their location within the spine cervical and the neck thoracic in the upper back lumbar in the lower back sacral in the pelvis and coxal at the base each region plays a specific role in supporting body weight facilitating movement and protecting the CNS the vertebral body composed of dense bone provides the primary support and stability for the spine bearing the weight of the body and facilitating movement the spinal canal a hollow passage within the vertebrae encases and protects the spinal cord safeguarding the delicate neural tissues from injury while allowing for the transmission of nerve impulses between the brain and the rest of the body together these structures maintain both the mechanical function of the spine and the protection of the CNS.",
        "Intervertebral Discs and Spinal Cord Protection": "Intervertebral discs are located between each vertebrae serving to cushion and separate them absorbing stress and allowing flexibility within the spinal column however excessive stress or trauma to the vertebral column can lead to injuries including damage to the spinal cord or nerve Roots peripheral nerve injuries which occur at the peripheral level of the nervous system may also result from such trauma the spinus process of the seventh cervical vertebrae located at the base of the neck is the most prominent and easily palpable of these structures the column has a significant range of motion allowing for both flexation and extension though extreme movements in either direction can strain or damage the structural ligaments that provide support to the spine.",
        "Brain Structure and Function": "The central nervous system specifically the brain serves as the center of Consciousness and regulates all higher order functions of the body the brain is divided into four major regions the cerebrum responsible for cognitive functions and voluntary actions the deylon which includes structures such as the thalamus and hypothalamus that regulate vital processes the brain stem controlling basic life functions like respiration and heart rate and the cerebellum which coordinates movement and balance the brain is the most metabolically active organ in the body and is highly sensitive to changes in profusion relying entirely on cerebral blood flow to meet its oxygen and nutrient demands any Interruption to this blood flow can result in immediate and significant damage to brain function.",
        "Cerebral Functions and Lobes": "The cerebral is responsible for higher cognitive functions and is divided into the right and left hemispheres the cerebral cortex which covers the cerebrum regulates voluntary skeletal movement and the level of awareness within the cerebrum the frontal lobe governs voluntary motor actions and personality traits the parietal lobe controls motor functions on the opposite side of the body as well as memory and emotion the occipital lobe is tasks with processing visual information making it essential for vision the speech center located in the temporal lobe manages language production and comprehension while the temporal lobe itself is also responsible for long-term memory as well as processing auditory taste and all Factory information each of these regions contributes to the complex integration of sensory and motor functions that are necessary for conscious living.",
        "Cerebellum and Brain Stem Functions": "The cerebellum assists in coordinating body movements ensuring smooth and balanced muscular activity the brain stem is responsible for controlling nearly all life sustaining functions and is composed of the midbrain ponds and medulla the reticular activating system or Ras that's located in the brain stem is essential for maintaining Consciousness the lower part of the brain stem contains centers that regulate fundamental functions such as heart rate breathing and blood pressure the basal ganglia help coordinate motor movements and maintain posture the pwns houses important nerve fibers that are involved in sleep regulation respiration and supports the medullary respiratory Center the medulla itself functions as a key conduction pathway for both ascending and descending nerve tracks carrying signals between the brain and the body.",
        "Spinal Cord and Meninges": "The spinal cord acts as the primary transmitter of nerve impulses linking the brain with the peripheral nervous system the cot aquana located at the lower end of the spinal cord consists of individual nerve roots that continue to relay messages to and from the lower parts of the body the meninges are protective layers that surround and enfold the entire central nervous system providing both physical protection and a barrier against infection the outermost layer known as the Duram matter is a tough fibrous wrapping that covers the entire brain and spinal cord folding in certain areas such as the tentorium to further compartmentalize and support the brain menial arteries are situated between the duramat and the skull supplying blood to these regions beneath the duramat lies the arachnoid a delicate transparent membrane that acts as the second menial layer the innermost layer the patter is a thin translucent and highly vascular membrane that closely adheres to the surface of the brain and spinal cord providing additional protection and nourishment through its rich blood supply.",
        "Peripheral Nervous System": "The peripheral nervous system consists of 31 pairs of spinal nerves and 12 pairs of cranial nerves these nerves extend from the central nervous system to various parts of the body facilitating communication between the brain spinal cord and peripheral tissues the spinal nerves emerge from the spinal cord and are responsible for transmitting sensory and motor signals to and from specific regions of the body while the cranial nerves primarily arise from the brain and are involved in controlling functions such as facial movement sensation and the operation of organs like the heart and lungs the submatic nervous system regulates voluntary activities such as the control of skeletal muscles allowing for conscious movement in contrast the autonomic nervous system governs the function of many vital organs such as the heart and lungs without voluntary control from the brain cranial nerves pass to the openings in the skull transmitting nerve impulses directly to or from the brain playing a role in functions like Vision hearing and swallowing.",
        "Sensory and Motor Nerves": "Peripheral nerves are responsible for conducting sensory impulses from the skin and various organs to the spinal cord sensory nerves carry information from the body to the brain through the spinal cord enabling the perception of Sensations like pain and temperature motor nerves transmit signals from the central nervous system to the muscles initiating movement connecting nerves facilitate communication between sensory and motor neurons and within the spinal cord these connecting nerves form a reflex arc allowing for Rapid automatic responses to certain stimuli such as pulling away from a hot object in the spinal cord the connecting nerves form a reflex arc which allows for an immediate response to certain stimuli without the need for brain involvement when a sensory nerve within this Arc detects an irritating or harmful stimulus it bypasses the brain and sends a direct message to the motor nerve this results in an immediate reflex of action such as pulling a hand away from a hot surface ensuring a rapid protective response that minimizes potential injury this mechanism exemplifies the body's ability to respond swiftly to Danger through automatic processes.",
        "Autonomic Nervous System": "The autonomic nervous system is divided into two main components the sympathetic and parasympathetic nervous systems the sympathetic nervous system which is regulated by the hypothalamus is responsible for the body's fight ORF flight response during stress an injury to the spinal cord at or above the level of T6 May disrupt sympathetic communication leading to complications such as autonomic dysreflexia the parasympathetic nervous system on the other hand is involved in conserving energy and maintaining normal organ function such as slowing the heart rate and promoting digestion disruption of the parasympathetic nerves in the sacral region can result in a loss of bowel and bladder control as well as impair sexual function demonstrating the critical role these nerves play in autonomic regulation of the lower body.",
        "Types of Head Injuries": "Head injuries are categorized into two main types closed and open head injuries closed head injuries are the most common and typically result from blunt trauma these injuries can cause skull fractures as well as focal and diffuse brain injuries and are often Complicated by increased intracranial pressure which can further compromise brain function open head injuries on the other hand occur when the Duram matter and cranial contents are penetrated with gunshot wounds being the most common cause these injuries nearly always result in significant neurological deficits and a decreased quality of life both types of head injuries present with similar signs and symptoms and any patient exhibiting one or more of these symptoms should be properly evaluated in the emergency department to prevent further complication in the next few slides we'll discuss many of these signs and symptoms.",
        "Scalp Lacerations and Skull Fractures": "Scalp lacerations even when small can lead to significant blood loss due to the rich vascular Supply in the scalp in patients with multiple injuries bleeding from scalp or facial lacerations can contribute to hypovolemia potentially complicating their clinical presentation additionally scalp lacerations can be an indicator of deeper more serious injuries to the skull or brain warranting a thorough evaluation to rule out underlying trauma skull fractures which can be classified as open or closed are serious injuries that may result from blunt or penetrating trauma in an open skull fracture the Duram matter and surrounding Tiss isssues are breached potentially exposing the brain and increasing the risk of infection such as menitis or en sephtis closed fractures in contrast involve a break in the bone without disruption of the overlying tissues but they can still lead to significant intracranial injury Key signs of a skull fracture include visible deformity to the skull which may be noticeable as a depression or irregularity upon palpation cracks in the skull may be observed through an accompanying scalp laceration further indicating the potential for underlying brain injury additionally two classic signs of Basler skull fracture are raccoon eyes and battle signs raccoon eyes refer to periorbital ecosis beneath the eyes which suggest the fracture has impacted the base of the skull battle sign is bruising behind the ear over the mastoid process indicative of a fracture near the temporal bone these clinical signs not only point to the presence of a skull fracture but also suggest the possibility of underlying damage to brain tissue cerebral spinal fluid leakage or vascular injury skull fractures may also be associated with an increased in cranial pressure bleeding or other complications making early detection and management vital to prevent further neurological deterioration.",
        "Types of Skull Fractures": "Linear skull fractures are the most common type of skull fracture characterized by a non-displaced break in the bone these fractures typically do not involve bone displacement meaning the bone remains in its normal position while they are often less severe than other types they still require careful evaluation to rule out underlying brain injury depressed skull fractures on the other hand occur when high energy direct trauma usually from a blunt object drives part of the skull inward the frontal emperial regions are the most susceptible due to their exposure and relatively thin bone structure in these cases bone fragments may be pushed into the brain causing significant damage patients with depressed skull fractures often present with neurologic symptoms such as unresponsiveness due to the direct injury in the brain tissue Basler skull fractures typically resulting from high energy trauma involve the base of the skull and can present with specific SIDS such as cerebral spinal fluid drainage from the ears indicating a tear in the Duram matter as stated previously other indic ators include raccoon eyes and battle signs both of which suggest a fracture at the base of the skull these are particularly concerning because they can lead to serious complications such as infection or damage to the cranial nerves open skull fractures are among the most severe as they involve a break in the scalp and skull that exposes brain tissue to the external environment this exposure dramatically increas inrees the risk of infection and results in a very high mortality rate especially if not treated immediately.",
        "Traumatic Brain Injuries": "Traumatic brain injuries or tbis are divided into two broad categories primary or direct injuries and secondary or indirect injuries primary brain injury occurs instantly as a result of a direct impact to the Head affecting the brain and its Associated structures at the moment of trauma this injury may include contusions lacerations or damage to blood vessels secondary brain injury however develops as a consequence of the initial injury and can occur over a range of time from minutes to several days after the primary insult secondary injuries are particularly harmful because they exacerbate the initial damage and are often the result of processes such as cerebral edema intracranial hemorrhage and increased intracranial pressure these conditions can lead to cerebral esea and hypoxia further compromising brain function infection may also set in if the injury involves open wounds or fractures preventable factors such as hypoxia and hypotension are significant contributors to secondary brain injury as they can worsen cerebral profusion and oxygenation.",
        "Mechanisms of Traumatic Brain Injury": "Motor vehicle crashes are the most common cause of traumatic brain injuries often leading to a specific type of injury known as a cou contra cou injury in this mechanism the brain strikes the inner surface of the skull at the point of impact or coup and then rebounds to to strike the opposite side of the skull Contra this causes damage to multiple areas of the brain following the initial trauma the injured brain typically swells due to cerebral vasod dilation which increases blood flow and exacerbates intracranial pressure this swelling can further compress brain tissue leading to secondary brain injury if not managed properly cerebral edema which contributes to further brain swelling may not manifest until several hours after the initial injury this delayed swelling exacerbates the risk of secondary brain injury by increasing intracranial pressure low oxygen levels in the blood aggravate cerebral edema worsening the condition while maintaining proper oxygenation is critical hyperventilation should be generally avoided as this can lead to cerebral Vaso constriction and decreased cerebral profusion the only appropriate indication for hyperventilation is when there are clear signs of cerebral herniation where increased intracranial pressure forces brain tissue to shift abnormally.",
        "Signs and Symptoms of Head Injuries": "A common response to head injuries is vomiting which in turn can increase the risk of aspiration if not properly managed the presence of any clear or pink watery cerebral spinal fluid from the nose ear or an open scalp wound indicates that both the Duram matter and the skull have been disrupted signifying a more severe injury with a higher risk of infection and brain damage seizures may also occur following head trauma adding further complication to the patient's neurological status Cushing's Triad is is a classic set of signs that indicates increased intracranial pressure and the effects of cerebral edema it consists of increased blood pressure often a widening pulse pressure a decreased heart rate and irregular respirations this Triad is a sign of impending brain stem compression and requires immediate intervention to prevent further neurological deterioration.",
        "Intracranial Pressure and Hematomas": "Intracranial pressure increases when there's bleeding inside the skull which can occur in several locations between the skull and Duram matter known as a epidural hematoma beneath the Duram matter but outside the brain known as a subdural hematoma within the brain tissue itself known as an intracerebral Hemorrhage or into the subarachnoid space known as a subar rid Hemorrhage as ICP Rises the brain is compressed against the cranium which can lead to further damage and impaired function normal ICP in adults ranges from 5 to 15 mm of mercury but as ICP increases it reduces cerebral profusion pressure which in turn decreases cerebral blood flow cerebral profusion pressure is the pressure required to maintain adequate blood flow through the brain with a minimum of 60 mm of mercury necessary to ensure proper brain perfusion in adults when cerebral perfusion pressure decreases the body responds to a process called Auto regulation where the mean arterial pressure increases causing cerebral Vasa dilation and boosting cerebral blood flow in an attempt to maintain adequate profusion how however this causes a rise in intracranial pressure which if left unchecked can cause cerebral blood flow to become severely compromised leading to eskema and further brain injury additionally late signs would include a unilaterally unequal in reactive pupil coma and abnormal posturing.",
        "Abnormal Posturing and Brain Injury": "There are two types of abnormal posturing decorticate and desate and they are indicative of severe brain injury and reflect the level and extent of damage to the CNS decorticate posturing also known as flexor posturing occurs when there's damage above the level of the brain stem typically involving the cerebral hemispheres internal capsule or Thalamus it's characterized by the flexation of the arms with the elbows bent and the hands clenched into fists while the legs remain extended and internally rotated this posture suggests significant damage but the brain stem will still relatively be intact allowing for some degree of neurological control on the other hand desate posturing also known as extensor posturing is a more severe sign and is often associated with an injury at the level of the brain stem or below such as damage to the midbrain or upper ponds in this posture both the arms and legs are extended and the arms rotated outward with the wrist and fingers flexed this posture indicates that the injury has progressed further down the brain stem affecting critical centers that control motor function and vital reflexes both types of posturing are signs of severe neurological compromise and they indicate that the brain is no longer able to properly regulate motor responses the presence of decorticate or desate posturing is an indicator of increasing intracranial pressure or brain herniation which can lead to irreversible damage or death because of this immediate intervention is required including aggressive measures to reduce ICP and maintain cerebral profusion as well as rapid transport to a facility capable of Neurosurgical intervention typically a level one trauma Center.",
        "Focal Brain Injuries": "A focal brain injury refers to a specific grossly observable injury to the brain often involving localized damage one example of a focal brain injury is a cerebral contusion where the brain tissue is bruised and damaged in a specific area this differs from a concussion which involves functional disturbances without structural damage the frontal lobe is the area that's most commonly affected by a cerebral contusion and the injury often leads to swelling potentially resulting an increased intracranial pressure an epidural hematoma is another type of focal brain injury that's characterized by the accumulation of blood between the skull and the Duram matter it typically occurs as a result of a Blow To The Head often causing a linear fracture of the temporal bone and disrupt ion of the middle menial artery patients with an epidural hematoma often lose Consciousness immediately following the injury followed by a brief period of regained awareness known as a lucid interval before deteriorating again as the hematoma expands and intracranial pressure increases immediate recognition in treatment are essential to prevent further neurological compromise and potential herniation.",
        "Subdural and Intracerebral Hematomas": "A subdural hematoma involves the accumulation of blood beneath the Duram matter but outside the brain tissue it's the most common type of intracranial hemorrhage and may or may not be associated with the skull fracture subdural hematomas typically result from the rupture of veins that bridge the cerebral cortex and Duram matter often due to head trauma or rapid acceleration de acceleration injuries patients with the subdural hematoma may present with a fluctuating level of Consciousness focal neurological signs such as weakness or numbness or slurred speech these symptoms can vary based on the rate of bleeding and the size of the hematoma subdural hematomas are classified as acute Subacute or chronic depending on the time of onset and progression of symptoms acute subdural homas generally develop rapidly within 24 hours of the injury while Subacute cases may take days to manifested and chronic subdural hematomas can evolve over weeks to months especially in older adults are those on anti-coagulant therapy an intracerebral hematoma occurs when blood accumulates within the brain tissue often resulting from trauma hypertension or the r rure of blood vessels this type of bleeding directly affects the brain's functional areas causing significant damage due to both the pressure exerted by the blood and the disruption of normal neural activity the expanding hematoma compresses surrounding brain tissue leading to increased intracranial pressure and reduced cerebral profusion which can result in brain esea and further injury because the brain is enclosed within the rigid skull there's a limited space for the hematoma to expand exacerbating the pressure on the vital brain structures and leading to potentially irreversible neurological damage even with surgical intervention the mortality rate for intracerebral hematomas remains High surgical evacuation is often Complicated by the Deep location of the bleed and the potential for further injury to delicate brain tissue during the procedure additionally postsurgical complications such as rebleeding cerebral edema and infection can occur the prognosis for patients depends on the size and location of the hematoma the speed of the medical intervention and the patients's overall health however due to the severity of brain damage many patients who survive typically experience long-term neurological deficits or impaired cognitive function.",
        "Subarachnoid Hemorrhage": "A subarachnoid hemorrhage occurs when bleeding enters the subarachnoid space where cerebral spinal fluid circulates this condition can be identified as bloody CSF and signs of menial irritation such as neck stiffness photophobia and kernig or brinsky signs subarachnoid hemorrhage is commonly caused by trauma the rupture of an aneurysm or an arterio Mal formation patients typically present with a sudden and severe headache often described as the worst headache of their life as the bleeding progresses signs of increased intracranial pressure such as altered mentation vomiting and possible herniation may appear requiring immediate medical intervention to prevent further complications.",
        "Diffuse Brain Injuries": "Diffuse brain injuries affect the entire brain in contrast to focal injuries that are localized a common type of diffus brain injury is a cerebral concussion which occurs when the brain is Jarred within the skull due to a Blow To The Head or face or from Rapid acceleration de acceleration forces such as a coup Contra cou injury concussions are considered mild traumatic brain injuries and are characterized by a rapid onset of short-lived neurological imp impairment that typically resolve spontaneously these injuries may or may not involve a loss of consciousness and it's impossible to rule out a concussion in any head injury case with transient neurological symptoms common features of a concussion include a direct Blow To The Head or transmission of force from the neck or body that impacts the brain patients with the concussion often exhibit signs such as confusion disorientation and Amnesia which may persist for several minutes it's important to inquire about specific symptoms in any patient with a head injury including dizziness weakness visual disturbances nausea vomiting ringing in the ears slurred speech and difficulty focusing other signs can include a lack of coordination delayed motor responses inappropriate emotional reactions temporary headaches and an overall disorientation the presence of any of these symptoms should prompt a thorough evaluation to determine the extent of the injury and guide appropriate management.",
        "Diffuse Axonal Injury": "Diffuse axonal injury or Dai is a severe form of brain injury often associated with a poor prognosis due to the widespread damage to nerve fibers throughout the brain this type of injury involves the stretching shearing or tearing of axons the long projections of nerve cells which disrupts normal brain communication and function daai typically results from high-speed rapid acceleration de acceleration forces such as those encountered in motor vehicle crashes or severe Falls where the brain is subjected to sudden movement within the skull the severity of diffuse axonal injury and the resulting prognosis depend on the extent of axonal damage Dai is classified as mild moderate or severe with severe cases often leading to prolonged unconsciousness significant neurological impairment or even death in milder cases patients may experience some recovery though long-term deficits in cognitive function motor skills or Consciousness may still persist.",
        "Mechanisms of Spinal Injuries": "Spinal injuries can occur through various mechanisms with common causes including compression injuries from Falls and Trauma from motor vehicle collisions or similar high impact events the mechanism of injury plays a key role in determining the type and severity of the spinal injury vertebral fractures can occur with or without Associated spinal cord injuries stable fractures typically pose less risk to the spinal cord whereas unstable injuries which involve damage to multiple Columns of the spine increase the likelihood of neurological damage flexation injuries which result from the forward movement of the head are commonly caused by rapid de acceleration such as motor vehicle accidents or by a direct blow to the oxy put these injuries May also involve lateral bending where the head is forced to one side in flexation compression mechanisms the head moves in a front to back motion overstretching one side of the neck while compressing the opposite side rotation with flexation particularly in the c1c2 region of the spine often results in unstable injuries due to the high velocity forces involved such as those encountered in car crashes or violent trauma vertical compression injuries occur when forces are transmitted through the vertebral bodies either directed inferiorly through the skull or superiorly through the pelvis or feet these injuries typically result from direct trauma such as a blow to the crown of the skull or from Rapid de acceleration following a fall where the body absorbs the impact vertically vertical compression can lead to fractures often without an Associated spinal cord injury though the vertebral bodies bear the brunt of the force however these types of injuries can cause herniation of the diss leading to compression of the spinal cord Andor the nerve roots in severe cases fragments of the vertebrae may actually break off and enter the spinal canal increasing the risk of spinal cord compression or other neurological complications even without direct damage to the spinal cord these injuries can result in significant long-term pain nerve impingement and mobility issues if not properly managed.",
        "Hyperextension and Distraction Injuries": "Hyperextension and distraction injuries involve different mechanisms that can severely affect the spine hyperextension refers to the excessive backward movement of the spine which can lead to fractures of the vertebral bones and injury to supporting ligaments distraction injuries occur when parts of the body are pulled in opposite directions resulting in Rapid hyperextension of the skull Atlas and axis as a unit the cervical spine particularly in the upper segments is most vulnerable to these forces due to its limited support and protection compared to other final regions the most classic form of distraction injury is The Hangman's fracture which involves a bilateral fracture of the C2 vertebrae and an Associated traumatic subluxation of C2 on C3 this type of injury is often caused by severe hyperextension typically seen in High Velocity trauma in many cases these injuries are also involved with mixed mechanisms where rotation flexation or extension forces act simultaneously further complicating the injury and increasing the risk of spinal cord involvement.",
        "Spinal Cord Injury Indicators": "Spinal cord injuries are often indicated by injuries to surrounding structures obvious trauma to the head or neck raises concerns for cervical spine injury while injury to the shoulders back or abdomen suggest possible thoracic or lumbar spine involvement in a similar fashion trauma to the lower extremities May indicate Associated damage to the lumbar spine or sacrum injuries to the cervical spine are particularly concerning because they can impair the function of the diaphragm which is innervated by the frenic nerve originating from the C3 to C5 levels this can lead to compromised respiratory function as the ability of the chest wall to fully expand is diminished cervical spine injuries therefore pose a significant risk to breathing and require immediate assessment and intervention to preserve respiratory function.",
        "Primary and Secondary Spinal Cord Injuries": "Primary spinal cord injury occurs at the moment of impact and involves immediate damage to the spinal cord a spinal cord concussion a form of primary injury is characterized by temporary dysfunction lasting between 2 4 and 48 hours after which function often returns a spinal cord contusion on the other hand involves more significant trauma and is commonly caused by a vertebral fracture dislocation or direct injury to the cord secondary spinal cord injury refers to the progression of damage following the initial primary injury this can result from factors such as hypoxemia hypog glycemia or hypothermia which exacerbate the initial trauma by further damaging the spinal cords neural elements preventing secondary injury is a critical aspect of spinal cord injury management this involves maintaining proper oxygenation and profusion to the spinal cord while simultaneously minimizing heat loss in order to reduce further deterioration of neural function.",
        "Spinal and Neurogenic Shock": "Spinal shock is a temporary neurologic condition that occurs immediately following spinal trauma often presenting with varying degrees of accute spinal injury during spinal shock sensory and motor function below the level of injury are impaired causing a loss of reflexes of muscle tone the duration of spinal shock can last anywhere from hours to weeks depending on the severity of the injury after which some function May grad ually return as the shock subsides neurogenic shock a distinct condition results from the temporary loss of autonomic nervous system function due to spinal cord injury usually at or above the T6 level a classic presentation of neurogenic shock includes a patient who is hypotensive in Broc cardic with skin that is warm flushed and dry below the level of the spinal leion this occurs because of the loss of sympathetic tone leads to unopposed parasympathetic activity causing vasod dilation and a drop in blood pressure immediate management focuses on maintaining blood pressure and addressing the underlying spinal injury.",
        "Emergency Care for Head Injuries": "When providing emergency medical care for a patient with a head injury it's essential to follow four core principles first establish and maintain a patent Airway to ensure proper oxygenation second control any active bleeding and ensure adequate circulation to support cerebral profusion as maintaining oxygen and blood flow to the brain is critical third initiate at least one 18 gauge IV line and administer isotonic crystalloid fluids as needed to support circulation finally a assess the patient's Baseline mental status and continuously monitor for any changes in neurological function in addition follow local protocols a medical Direction regarding the use of hyperventilation if signs of cerebral herniation are present avoid applying pressure to open or depress skull fractures to prevent further damage along with these actions it's important to assess and treat other injuries dress and bandage open wounds splint fractures and anticipate complications such as vomiting seizures or sudden changes in the patient condition shock in a patient with a traumatic brain injury is often due to hypovolemia rather than neurogenic shock to manage this establish at least 11 18 gauge IV and administer normal saline or lactated ringers to maintain adequate circulation the only indication for administering glucose in a patient with a head injury is confirmed hypoglycemia as unnecessary glucose Administration can actually worsen cerebral edema if hypotension does develop carefully Infuse isotonic crystalloids to maintain profusion being mindful of fluid overload which could exacerbate cerebral swelling additionally ensure the patient does not become overheated as hypothermia can increase metabolic demands in the injured brain and morson outcomes maintaining proper temperature control is important in minimizing further damage.",
        "Managing Scalp Lacerations": "Scalp lacerations can contribute significantly to hypovolemia particularly in patients with multiple injuries due to the rich vascular Supply in the scalp these injuries often indicate the presence presence of deeper more serious trauma such as skull fractures or brain injury to control bleeding apply direct pressure using a dry sterile dressing if there are avulsions gently fold the skin back onto the wound bed before applying pressure avoid excessive pressure on open wounds especially if there's a concern for underlying fractures if the dressing becomes soaked remove it and reassess the area to ensure pressure is being applied correctly and effectively.",
        "Spinal Injury Immobilization": "In the emergency care of spinal injuries immobilization of the cervical spine is critical to prevent further damage from potentially fractured bone fragments stabilizing the head and trunk is key in reducing the risk of exacerbating spinal cord injury when performing manual inline stabilization follow the appropriate procedural steps to ensure proper technique it's important to never Force the head into a neutral inline position as doing so could worsen the injury if the patient reports muscle spasms in the neck increased pain with movement numbness tingling or weakness in the arms or legs or if the airway or ventilation becomes compromised cease any further attempts to move the head in such cases prioritize stabilizing the patient in their current position while ensuring adequate Airway management and spinal immobilization cervical collars provide preliminary partial support for patients with potential spinal injuries they should be applied to any patient where the spinal injury is suspected based on the mechanism of injury medical history or the presence of signs and symptoms indicative of spinal trauma it's important to avoid moving the cervical spine during patient transfers and supplement the collar with another spinal motion restriction device such as a backboard when indicated a rigid cervical collar must be the correct size for the patient to provide effective immobilization if an appropriately sized collar is unavailable a rolled towel may be used around the patient's head as a temporary alternative as opposed to placing an incorrectly sized collar when applying the collar follow the steps as prescribed in your local procedure after immobilization always assess pulse motor and sensory function in all extremities to ensure there is no loss of function manual support for the cervical spine should be maintained until the patient is fully secured to a backboard or other appropriate immobilization device.",
        "Helmet Removal Considerations": "When treating a patient who is wearing a helmet several important questions should guide your decision-making process first assess whether the patient's Airway is clear and whether they are breathing adequately it's critical to determine whether you can maintain the airway and assist ventilation if the helmet remains in place check if the face guard can be easily removed to provide Airway access without needing to remove the entire helmet evaluate how the helmet fits and determine whether the patient's head can move within the helmet which could affect spinal immobilization efforts finally assess whether the patient's spine can be immobilized in a neutral position with the helmet on if the helmet compromises Airway management restricts spinal immobilization or does not fit properly its removal should be considered following local protocols for safe helmet removal a helmet that fits well can prevent the patient's head from moving and should be left in place under certain conditions specifically the helmet should remain on if there are no Airway or breathing issues it does not interfere with the assessment or treatment of Airway or ventilation problems spinal immobilization can be achieved effectively and or removing the helmet would risk further injury to the patient that being said a helmet should be remove removed if it is a full face helmet as it makes assessing or managing the airway difficult and if removing the face guard to improve Airway access is not possible additionally if the helmet prevents proper spinal immobilization allows excessive head movement or if the patient's in Cardiac Arrest it should be removed immediately to facilitate appropriate Emergency Care.",
        "Sports and Motorcycle Helmet Removal": "Sports helmets are generally open in the front and may or may not include an attached face mask in situations where Airway access is needed the face mask can typically be removed by cutting or unfastening the straps that secure it to the helmet this allows access to the patient's Airway without needing to fully remove the helmet which can help maintain spinal stabilization during treatment motorcycle helmets often have a shield that covers the face if the shield cannot be removed to allow for Airway access the helmet itself must be taken off the preferred method for helmet removal requires at least two people as it's a delicate procedure that depends on the type of helmet being used one provider must provide constant inline support of the head and neck while the other carefully removes the helmet it's important that both providers do not move simultaneously to maintain spinal alignment remember you do not need to remove a helmet if the airway is accessible the patient's head is snugly positioned in the helmet and the helmet can be securely immobilized along with the patient to a backboard or other spinal immobilization device the alternative method for a helmet removal involves applying less force and slightly more time consuming but it can be beneficial in certain situations to reduce the risk of further injury the steps for this method are as follows first remove the chin strap to release any tension securing the helmet next remove the face mask to provide better access to the patient's Airway and face pop the jaw pads out of place using a tongue depressor to allow for easier helmet removal place your fingers inside the helmet and gently rock it back off the top of the head ensuring careful movement to min miniz neck or spinal motion the person at the side of the patient should control the head by holding the jaw with one hand and the oxy put in the other maintaining inline stabilization throughout the process once the helmet is removed insert padding behind the oxop put to prevent neck extension if the patient's wearing shoulder pads ensure that appropriate padding is applied behind the head to prevent hyperextension lastly the person positioned at the patient's chest is responsible for ensuring that the head and neck do not move during the removal process.",
        "Pediatric Spinal Immobilization": "Small children often require additional padding to maintain a neutral inline position during immobilization due to their anatomical differences such as smaller Airways and proportionally larger heads these factors necessitate padding to maintain an open Airway and proper spinal alignment to achieve this place padding under the child's shoulders extending to the toes as needed to accommodate for the larger head and help keep the airway neutral use blanket rolls or similar supports between the child and the sides of an adult-sized backboard to prevent lateral movement and ensure stability during transport this careful padding and positioning ensure that the child's spine remains properly immobilized while maintaining Airway patency.",
        "Non-Traumatic Spinal Conditions": "Non-traumatic spinal conditions such as back pain are among the most common physical ailments experienced by individuals the upright posture humans maintain places significant pressure on the lumbar spine making this area particularly vulnerable to strain and injury most people are susceptible to spinal injuries or degenerative diseases over time due to daily wear and tear in addition to degenerative conditions spinal tumors can lead to severe pain and physical disability while many cases of low back pain are idiopathic meaning there's no specific cause that can be identified it's important to carefully assess the patient's medical history including their medications which may provide insight into potential underlying conditions or management strategies for their back pain back back pain may arise from strain or sprain of the par vertebral muscles and supporting ligamentous structures without significant injury to nerve elements this type of pain is typically muscular skeletal in nature and does not involve substantial nerve damage however older adults particularly women with a history of osteoporosis are at a high risk for spontaneous compression fractures which can occur without significant trauma additionally tumors from metastatic carcinomas May Infiltrate The Spine leading to pathologic fractures degenerative dis disease is a common condition and disc herniation may occur in patients with pre-existing disc generation often triggered by some degree of trauma herniations most commonly affect The L4 L5 and L5 S1 regions though though they may also occur in the cervical spine at C5 C6 and C6 to C7 in the prehospital setting management of low back pain in the absence of trauma is primarily focused on providing Pala of care including positioning for comfort and addressing pain symptoms.",
        "Summary of Head and Spine Injuries": "This lecture on head and spine injuries covers the key components of traumatic brain injury and spinal cord injury focusing on Anatomy pathophysiology and emergency medical care in it we discuss the complexity of the nervous system which includes the brain spinal cord and peripheral nervous system we highlight the difference between head injuries such as traumatic brain injuries and spinal injuries specific terms like closed and open head injuries as well as primary and secondary brain injuries are explained along with the importance of controlling intracranial pressure and the dangers of cerebral edema we note how low oxygen levels and increased intracranial pressure can worsen the patient's condition for spinal injuries we discussed different mechanisms including compression flexation and hyperextension injuries various types of fractures including stable and unstable fractures are covered as well as the significance of cervical spine injuries which can affect breathing due to D diaphragm paralysis we outline key Emergency Care practices including Airway management immobilization techniques using cervical collars and backboards and the criteria for helmet removal non-traumatic spinal conditions such as degenerative disc disease and compression fractures are also addressed emphasizing pallative care in the absence of trauma"
    },
    {
        "Introduction to Abdominal and Genitourinary Injuries": "chapter 32 abdominal and Genet urinary injuries the ab the lower of the two major body cavities extends from the diaphragm to the pelvis and contains vital organs involved in the digestive urinary and Geno urinary systems while any of these organs may be injured in trauma some are better protected anatomically than others injuries to the abdomen particularly when unrecognized or untreated are a significant cause of traumatic death with Pediatric patients being especially vulnerable despite this injuries to the abdominal and Geno urinary systems are often overlooked even though approximately 10% of all trauma patients present with some form of Geno urinary injury a high index of Suspicion and prompt intervention are therefore imperative for patient survival.",
        "Abdominal Quadrants and Organ Locations": "the abdomen is divided into four quadrants by two perp pendicular lines intersecting at the umbilicus these quadrants include the right upper left upper right lower and left lower quadrants the location of pain or bruising in a specific quadrant can provide valuable information regarding which organs may be affected in a traumatic injury in the right upper quadrant the liver gallbladder dadum and a portion of the pancreas are located the left upper quadrant contains the stomach spleen and part of the pancreas the left lower quadrant houses portions of the large and small intestines specifically the descending colon while the right lower quadrant contains sections on the large and small intestines including the ascending colon and appendix the diaphragm acts as the anatomical boundary between the thoracic and abdominal cavities.",
        "Hollow vs Solid Organs in Abdominal Trauma": "Hollow and solid organs play different roles in abdominal trauma it's important to note that a patient can lose their entire circulating blood volume into the peritoneal cavity without any external signs of bleeding hollow organs such as the intestines and bladder are structures through which material passes and these organs tend to be more resilient to blunt trauma and are less likely to sustain injury unless they are filled at the time of impact solid organs such as the liver spleen pancreas and kidneys are dense and highly vascular meaning that they contain a rich blood supply when these organs sustain trauma particularly from blunt or penetrating forces they are at risk of significant hemorrhage due to the rupture of blood vessels this internal bleeding can be substantial as the Partin neoc cavity can hold large volumes of blood without external signs the onset of abdominal pain following trauma to solid organs is typically slow and Insidious unlike hollow organs which may cause immediate symptoms due to perforation and leakage of contents the damage to solid organs often results in a gradual accumulation of blood within the abdomen this delay in symptom presentation can make it challenging to identify the injury early potentially leading to life-threatening internal bleeding that may go unnoticed until the patient exhibits signs of shock or hemodynamic instability therefore a high index of Suspicion is necessary when assessing patients with abdominal trauma even if their initial presentation appears stable or pain is not immediately severe prompt Imaging and intervention are key to managing these injuries effectively.",
        "Anatomical Diagrams and Organ Locations": "in the first image we see the organs contained within the peritoneum key organs in the space include the liver stomach spleen and portions of the intestines including the ascending and transverse colon the diagram also marks the diaphragm as the dividing line between the thoracic and abdominal cavities the second image shows the retr parital space which houses organs such as the kidneys pancreas and major blood vessels like the aorta and Vena the dadum and parts of the colon are also present in the space along with the ERS the final diagram focuses on the pelvic cavity highlighting the rectum bladder uterus and females Sigman colon and iliac vessels these anatomical distinctions are important for understanding into different locations of potential injuries bleeding patterns and how symptoms may vary based on the involved organs and their relative protection within the perianal retroperitoneal or pelvic spaces.",
        "Genitourinary System Overview": "the Geno urinary system consists of two closely related systems the urinary and reproductive the urinary system is responsible for filtering waste products from the blood through the kidneys and controlling the discharge of these waste materials in the form of urine it plays a vital role in maintaining fluid and electroly balance in the body the reproductive system on the other hand manages the reproductive processes that are essential for the creation of Life both systems are anatomically linked and share proximity in the pelvic region making them susceptible to injuries from trauma particularly in cases involving blunt or penetrating Force.",
        "Complications of Abdominal Trauma": "Hemorrhage both external and internal is a primary concern for abdominal trauma potentially leading to life-threatening conditions in addition to blood loss injuries to both Hollow and solid organs can cause the spillage of their contents into the abdominal cavity resulting in complications such as peritonitis or pneumo perenium when Hollow or solid organs are comp compromised the irritation of nerve endings within the peronal cavity triggers localized pain if the contamination is contained however if the spillage spreads throughout the cavity the pain becomes generalized peritonitis refers to a severe often life-threatening inflammatory response within the peritoneum characterized initially by intense abdominal pain tenderness and muscle spasm another complication num numo perenium occurs when free air enters the peronal cavity often due to the rupture of a hollowed organ perforation from a peptic ulcer recent abdominal surgery or a ruptured abscess.",
        "Closed Abdominal Injuries": "closed abdominal injuries which are common in blunt trauma can be caused by compression or de acceleration forces compression injuries Ty Al result from forces like a poorly positioned lap belt during a vehicle collision the pressure exerted by the belt can deform hollow organs increasing the internal pressure within the abdominal cavity and leading to potential rupture or damage to these structures de acceleration injuries occur when a person or the vehicle they are in suddenly strikes a large immovable object such as a car crash the abrupt stop caus causes the organs inside the body to continue moving at a high speed potentially leading to shearing forces and internal damage particularly to solid organs such as deliver and spleen these types of injuries can result in significant internal bleeding organ rupture or both Crush injuries in the abdomen result from significant external forces at the time of impact often compressing the abdominal cavity between two objects these forces put solid organs such as the liver spleen and kidneys at the greatest risk of injury due to their density and Vascular nature such injuries can lead to severe internal bleeding and organ rupture additionally shearing forces during trauma can cause tears and structures like the ligamentum teres hepatus which connects the liver to the interior abdominal wall these tears may lead to Serious Hemorrhage and require immediate medical intervention to control bleeding and prevent further complications.",
        "Injuries from Seat Belts and Airbags": "injuries from seat belts and airbags are common in motor vehicle collisions and can lead to significant blunt trauma to the abdominal organs seat belts while designed to protect can cause harm if improperly positioned when worn too high the belt can compress abdominal organs or major vessels against the spine leading to severe internal injuries if used without a lap belt diagonal shoulder safety belts can cause trauma to the upper part of the trunk including injuries to the chest and upper abdominal organs airbags although protective can pose a risk to small children in shorter individuals seated in the front of the vehicle when deployed the force of the airbag can can result in injury to these individuals especially if they are seated too close to the dashboard it's also important to inspect beneath the airbag for any signs of damage to the steering wheel as this may indicate the extent of the force exerted during the collision and potential injuries to the driver.",
        "Open Abdominal Injuries": "open abdominal injuries such as gunshot and stab wounds present unique challenges in trauma care due to the potential involvement of multiple vital structures gunshot wounds commonly affect the small bowel colon liver and major blood vessels often resulting in significant Hemorrhage and organ damage due to the high velocity impact and widespread tissue disruption in contrast stab wounds tend to involve the liver small bowel diaphragm and colon depending on the location in depth of the penetration both types of injuries require immediate and thorough assessment as they can lead to severe internal bleeding contamination of the abdominal cavity and peritonitis if not managed properly this image highlights the severity of open abdominal trauma particularly in cases involving impalement injuries it also emphasizes the importance of proper stabilization both in prehospital and emergency care settings as well as a need for immediate surgical intervention to manage severe trauma control bleeding and prevent complications such as infection or peritonitis.",
        "Evisceration and Diaphragm Injuries": "evisceration is a severe type of abdominal injury where the trauma penetrates completely through the skin muscle layers and fascia resulting in the protrusion of internal organs most commonly the bowel through the wound this type of injury is typically the result of penetrating trauma such as stab wounds or deep lacerations evisceration exposes internal organs to the external environment increasing the risk of contamination infection and peritonitis injuries to the diaphragm are serious and can lead to the displacement of abdominal organs into the thoracic cavity a condition known as diaphragmatic herniation when this occurs patients May exhibit significant respiratory distress including dnia abnormal respiratory sounds and a scaffo or sunken or concave appearance of the abdomen the displacement of abdominal contents can compress the lungs reducing lung capacity and leading to ventilatory compromise patients with a ruptured diaphragm may experience heightened anxiety and worsening shortness of bre breath particularly if they are placed in a Seine position as this position further shifts abdominal organs upward exacerbating the respiratory difficulty it's important to recognize that inury to the diaphragm can present with signs and symptoms of impaired ventilation such as shallow or rapid breathing cyanosis and acccessory muscle use requiring prompt intervention to stabilize the patient respiratory function.",
        "Kidney and Liver Injuries": "the kidneys are the most common injured organs in the Geno urinary system particularly in cases of blunt trauma blunt renal trauma often occurs when the kidneys are compressed between the lower ribs and the lumbar spine a frequent consequence of motor vehicle accidents or Falls a ruptured kidney typically presents with pain in the abdomen and flank areas which may worsen during inspiration due to the movement of the diaphragm in cases of repeating renal trauma injuries are more likely to involve adjacent structures such as the liver lung and spleen making isolated kidney injuries uncommon clinicians should suspect kidney damage in patients with visible signs of trauma to the flank region such as abrasions lacerations contusions or hematomas additionally penetrating wounds to the area below the the rib cage and above the hip or the upper abdomen may also indicate renal injury fractures of the lower ribs thoracic vertebrae or upper lumbar vertebrae can further suggest the possibility of kidney damage the liver and spleen are highly vascular organs that are particularly susceptible to trauma and injuries to either can lead to Rapid and severe internal bleeding penetration or rupture of the liver can quickly result in signs of shock due to the liver's excessive blood supply patients with trauma to the right side of the chest or abdomen should be evaluated for potential liver injury in some cases patients May report referred pain to the right shoulder which is a sign of that blood or irritation is affecting the diaphragm given the liver's location and its role in filtration and blood storage injuries here can rapidly lead to life-threatening Hemorrhage.",
        "Spleen and Pancreas Injuries": "the spleen is also highly vascular and the potential for rupture increases when the spleen is enlarged as seen in conditions like mononucleosis or other underlying diseases when the spleen ruptures large volumes of blood can spill into the perinal cavity leading to signs of hypothalamic shock suspected spleen injuries could be considered in patients with upper left qu quadrant tenderness hypotension and tacac cardia especially if there are fractures of the 9th through 10th ribs on the left side injuries to the pancreas typically require a high energy force such as that from a motor vehicle collision or significant blunt trauma patients with pancreatic injuries often present with vague upper and mid abdominal pain which may radiate to the back due to the retrop perenial location of the pancreas these symptoms can be non-specific and the patient may not exhibit overt signs immediately after the injury peronal irritation May develop hours later leading to worsening abdominal pain and tenderness as inflammation sets in.",
        "Intestinal and Stomach Injuries": "penetrating trauma is the most common cause of injury to the intestines while blunt trauma to the abdominal wall often results in damage to the dadum dadal injury May manifest as back pain and if dadal contents leak into the retrop perenium this can lead to abdominal pain fever and eventually signs of perianal irritation patients may also experience delayed symptoms such as nausea vomiting and abdominal discomfort injuries to the stomach typically occur due to penetrating trauma though blunt abdominal trauma can also affect the small and large intestines as well as the stomach a rupture of the stomach presents with rapid onset burning epigastric pain abdominal rigidity and rebound tenderness indicating severe irritation of the peritoneum from gastric contents these injuries are often accompanied by signs of sepsis or shock if not treated prly as contamination of the abdominal cavity can rapidly lead to infection and systemic inflammation.",
        "Bladder and Genital Injuries": "injuries to the urinary bladder are commonly associated with pelvic fractures as the bladder is situated within the Bony pelvis and can be compressed or ruptured during trauma bladder injury should be suspected in any patient who has sustained trauma to the lower abdomen or pelvis particularly in the presence of pelvic fractures blunt trauma to this region can lead to rupture of the blad especially if the bladder is full at the time of injury when the bladder ruptures urine can spill into various parts of the abdominal cavity leading to different types of rupture intra parital within the peronal cavity extra peronal outside of the perial cavity or retr peronal behind the perenium this urine leakage can cause significant irritation and inflammation of the surrounding tissues increasing the risk of infection and sepsis if not promply identified and managed in the emergency setting signs of a bladder injury may include lower abdominal pain difficulty or inability to urinate and signs of peritonitis if urine has contaminated the peronal cavity rapid diagnosis and appropriate intervention often involving surgical repair are necessary to prevent complications enturies to the external male genitalia can vary widely with potential complications ranging from Pain and discomfort to long-term effects on fertility and function testicular torion occurs when the spermatic cord becomes Twisted cutting off the blood supply to the testicle this condition requires immediate intervention to preserve testicular function blunt trauma to the testicles or scrotal sack can result in a range of injuries from simple contusions to rupture of the testicle and in rare cases torsion in severe cases testicular trauma can result in loss of fertility which is the primary concern for patients with obvious penetrating trauma to the scrotal area a high index of Suspicion should be maintained for Associated injuries to the surrounding structures such as the penis ureth ra or other parts of the Geno urinary system penile injuries may result from blunt or penetrating trauma but can also arise due to sexual activities or self-inflicted injuries a fractured penis although uncommon can occur when an erect penis is forcefully impacted against a partner's pubic symphysis or when it's bent too far through manipulation this injury requires urgent medical attention to prevent long-term damage or deformity penetrating trauma to the penis was commonly caused by gunshot wounds poses additional risks of vascular damage infection and impaired urinary function all penile injuries should be carefully evaluated to ensure that there is no underlying damage to the urethra or surrounding structures injuries to the female genitalia are relatively uncommon due to the Deep positioning and protection provided by the pelvic bones the uterus ovaries andal opian tubes are typically shielded from trauma because they small size and location within the pelvis however penetrating trauma such as stab wounds or gunshot wounds to the lower pelvis can cause significant damage to these reproductive organs as pregnancy progresses the uterus enlarges and Rises out of the pelvic cavity making it more vulnerable to both blunt and penetrating trauma pregnant patients are at a higher risk for developing signs and symptoms of shock due to the increased blood supply to the uterus and the growing fetus it's important to inquire about the patient due date and communicate this information to the hospital staff in order to ensure appropriate care for both mom and fetus pregnant patients are also susceptible to aine hypotensive syndrome which occurs when the enlarged uterus compresses the inferior vnea leading to decreased Venus return and subsequent hypotension to prevent this the patient should be placed on her left side which helps relieve the pressure on the vena and improves blood flow injuries to the external female genitalia such as lacerations abrasions or contusions can occur due to blunt or penetra in trauma and these injuries should be treated as soft tissue injuries additionally it's important to help determine if the patient is pregnant as this will influence both the clinical management and the urgency of care.",
        "Vascular Injuries and Signs": "vascular injuries resulting from blunt trauma can involve significant damage to the blood vessels within the intra parital space such as the aorta mesenteric vessels and smaller arteries and veins these injuries can often be masked by other trauma making their recognition challenging the severity of the injury depends on the number of vessels involved and how much time has passed since the injury as delayed recognition can result in substantial internal bleeding and hemodynamic instability the clinical presentation of vascular injuries varies based on whether the bleeding is contained within the abdominal cavity or or if there is active Hemorrhage a common sign of internal bleeding in the abdomen is rigidity where the abdomen feels almost Bor likee upon palpation in some cases per umbilical bruising or ecosis known as Cullen sign may be present indicating retrop peronal bleeding one specific concern for abdominal vascular injuries is the potential for an abdominal aortic aneurysm or AAA which could have deved veled prior to the trauma and worsened as a result of the injury this poses an immediate life-threatening risk and requires rapid identification and surgical intervention rectal bleeding is another important consideration and can result from a variety of causes including Trauma from sexual assault rectal foreign bodies hemorrhoids colitis or digestive tract ulcers it's crucial to differentiate between the causes of rectal bleeding to appropriately manage the patient and address any underlying conditions contributing to the bleeding.",
        "Management of Blunt Abdominal Trauma": "for patients presenting with blunt abdominal trauma several key interventions are necessary to ensure proper stabilization and Care spinal immobilization or spinal motion restriction should be performed to prevent further injury if there is any suspicion of spinal involvement administer high flow oxygen to optimize oxygenation and support tissue perfusion in cases of an unstable pelvis the use of a Pneumatic anti-shock garment may be indicated depending on local protocols these patients require rapid transport to the closest and most appropriate trauma facility additionally it's important to provide emotional and psychological support to the patient during transport to help reduce anxiety and improve their overall outcome in cases of blunt or closed abdominal injuries pain is often the patient's primary complaint however Tac cardia is the most common physiological sign indicating significant abdominal injury as it suggests blood loss or shock visible bruising or other external marks could alert clinicians to potential underlying injuries with the location of the bruising serving as a guide to which internal organs may be affected though these signs may not be readily available just after injury there are several specific signs that are important to the assessment of blunt abdominal trauma car sign is pain referred to the tip of the left shoulder and typically indicates bleeding into the peronal cavity from a splenic injury the gray Turner sign is bruis in the right upper quadrant left upper quadrant or flanks suggesting injury to the liver spleen or kidneys and lastly as mentioned previously Cullen sign is bruising around the umbilicus indicating internal abdominal bleeding often from a ruptured organ another important finding is guarding where the patient either intentionally or unintentionally stiffens the abdominal muscles in response to pain or injury this reflexive stiffening is a protective mechanism against further damage closed abdominal injuries may present only with minimal external signs such as abrasions or superficial bruising making a thorough clinical examination and a high index of Suspicion essential for identifying the true extent of internal damage.",
        "Internal Damages from Blunt Abdominal Injuries": "patients with blunt abdominal injuries may present with a range of internal damages that require immediate attention injuries can include severe bruising of the abdominal wall often a visible indicator of deeper trauma internal injuries may involve the laceration of the liver or spleen which are highly vascular and prone to Hemorrhage or the rupture of hollow organs such as the intestine gallbladder or stomach leading to contamination of the abdominal cavity trauma may also cause tears in the mesentary which could disrupt blood supply to portions of the bowel or the rupture or evulsion of the kidneys from their supporting structures the urinary bladder may also rupture particularly in association with pelvic fractures resulting in urine leakage into the abdominal cavity severe trauma can lead to massive intraabdominal Hemorrhage requiring rapid diagnosis and management one of the key complications of hollow organ rupture is peritoneal irritation and inflammation which occurs as the contents of the rupture organ spill into the peronal cavity leading to peritonitis if you suspect a diaphragmatic injury prioritize the patient Airway breathing and circulatory status as these injuries can severely compromise respiratory function immobilization is essential for any patient with a suspected blunt abdominal injury to prevent further trauma and stabilize any Associated injuries continuous monitoring for shock is critical as internal bleeding may not be immediately apparent but can rapidly lead to hypovolemia or shock finally ensure the patient is kept warm to prevent hypothermia which can exacerbate shock and worsen the patient's condition.",
        "Management of Open Abdominal Injuries": "in cases of open or penetrating abdominal injuries it should always be assumed that the object has penetrated the peritoneum and entered the abdominal cavity potentially causing damage to one or more internal organs these injuries require immediate and careful management to prevent further complications if the penetrating object is still in place do not remove it this object may be tampon Notting The Vessel or an organ and its removal could cause uncontrolled hemorrhage instead the object should be stabilized in its current position using bulky dressings to prevent movement and minimize further injury in cases of significant injury initiate two 18 gauge or larger IV lines or follow your local protocols IV access allows for Rapid fluid resuscitation but care must be taken when managing fluid volume increasing blood pressure can exacerbate internal bleeding so fluids should be administered judiciously aiming to maintain profusion to vital organs without causing a marked increase in blood pressure that could lead to more Hemorrhage this strategy known as permissive hypotension is often employed in trauma management to balance the need for profusion with the risk of worsening internal bleeding.",
        "Abdominal Evisceration Management": "abdominal evisceration occurs when internal organs typically parts of the bowel protrude through an open wound in the abdominal wall this is a serious medical emergency that requires careful management to prevent further injury and contamination do not apply pressure to the patient's abdomen under any circumstances as this can cause further damage to the organs and surrounding structures perform only a visual assessment of the injury and avoid any manipulation of the exposed organs or the wound never attempt to replace any organ that is protruding from the abdomen instead cover the eviscerated organ with sterile GS compresses that are moistened with sterile saline solution to keep the tissue from drying out after applying the moisten Galls secure it with a dry sterile dressing to protect the area from further decontamination provide any additional emergency care as needed including monitoring for signs of shock maintaining the the patient's Airway and administering IV fluids if necessary prompt transport to an emergency department is critical as the patient will require surgical intervention to repair the damage and manage any internal injuries.",
        "Open Abdomen Management": "when managing an open abdomen such as in cases of evisceration several key steps are important to prevent heat loss and protect the exposed organs the open abdomen radiates body heat rapidly leading to significant heat loss which can contribute to hypothermia therefore it's important to cover the exposed area to maintain the patient's Body temp cover the wound with a moistened sterile dressing using sterile saline solution to keep the exposed organs moist depending on local protocols you can also apply an eclusive dressing to protect the wound and prevent contamination this should go over the moist and sterile dressing and not come in contact with the organ itself once the dressings are in place secure them with the bandage to hold the dressing firmly over the wound without applying pressure to the abdomen finally use tape to secure the bandage ensuring that it stays in place during transport and further care avoid wrapping too tightly to prevent restricting blood flow or causing further injury.",
        "Kidney and Bladder Injury Management": "kidney injuries can be serious especially if associated with significant blood loss which may lead to signs of shock such as a rapid pulse low blood pressure and cool clammy skin hematuria or blood in the urine is a common indicator of kidney trauma and should prompt immediate concern in managing kidney injuries the priority is treating shock through fluid resuscitation and addressing any other Associated injuries rapid transport to the hospital is essential for further diagnostic evaluation including Imaging and possible surgical intervention for urinary bladder injuries the presence of blood in the urethal opening or physical signs of trauma to the lower abdomen pelvis or perineum should raise suspicion of bladder rupture particularly in the context of pelvic fractures the urgency of Transport is dictated ated by the presence of associated injuries or signs of shock with immediate transport required in cases of hemodynamic instability both kidney and bladder injuries require prompt recognition management and transport to prevent further complications.",
        "Management of External Male Genitalia Injuries": "injuries to the external Mel genitalia can be extremely painful and patient Comfort should be a priority cover areas that have been stripped of skin with sterile moist compresses and use dry sterile Galls to apply direct pressure and control bleeding it's important to never move or manipulate impelled instruments or foreign bodies in the urethra if parts of the genitalia such as the penis or testicles have been evoled they should be identified and transported with the patient to the hospital whenever possible in cases of penile amputation managing blood loss is the primary concern however it's critical not to apply constricting devices to control bleeding for testicular injuries suspect testicular torsion when there has been direct trauma to the testicles as this condition requires immediate intervention additionally no attempts should be made to remove tight objects constricting the penis or testicles in the field as these require Hospital level care for a safe removal all external genital injuries require careful management to prevent further harm and ensure rapid transport to a hospital for definitive treatment.",
        "Management of Female Genitalia Injuries": "injuries to the female Genelia such as lacerations abrasions and avulsions should be treated by covering the affected area with moist sterile compresses to control bleeding local pressure should be applied and a diaper type bandage can be used to secure the dressings in place any forign bodies present should be stabilized with bandages to prevent further injury bleeding from these injuries can usually be managed with local compression but more severe injuries or those involving contusions and blunt trauma require inhospital evaluation to assess for internal damage the urgency of Transport will depend on the extent of associated injuries the amount of hemorrhage and whether the patient is showing signs of shock in cases where sexual assault is suspected do not examine the genitalia unless it's absolutely necessary to address obvious bleeding preserving the Integrity of forensic evidence is critical and examination should be deferred to a medical professional in a controlled environment unless Immediate Care is required.",
        "Conclusion on Abdominal and Genitourinary Trauma": "in abdominal and Geno urinary trauma injuries to the abdominal cavity are significant due to the vital organs house within the abdomen stretching from the diaphragm to the pelvis contains organs from the digestive urinary and reproductive systems trauma to these organs especially when unrecognized or untreated Remains the leading cause of traumatic death particularly in pediatric patients a high index of Suspicion is necessary as about 10% of trauma patients present with some form of Geno urinary injury the location of bruising or pain in the abdominal quadrants can help determine which organs are likely affected in a traumatic injury whether involving the liver spleen intestines or kidneys injuries to hollow and solid organs present different clinical concerns hollow organs such as the intestines tend to be more resilient to blunt trauma unless they're filled whereas solid organs such as Deliverance spleen are prone to Hemorrhage upon rupture a patient can lose all circulating blood volume into the peronal cavity without visible external bleeding trauma can also lead to complications like peritonitis a potentially life-threatening inflammatory reaction or pneumo parium which occurs when free air enters the peronal cavity following the rupture of a hollow organ both conditions require prompt identification and intervention specific organ injuries such as those to the diaphragm kidneys liver and spleen can lead to distinctive signs and symptoms for example a ruptured diaphragm may cause disia abnormal respiratory sounds and abdominal deformity while kidney injuries often manifest as hematuria and flank pain bladder injuries particularly associated with pelvic fractures can lead to urine leakage into the abdominal cavity external in injuries to the genitalia whether male or female require careful handling with efforts focused on maintaining patient Comfort controlling bleeding and stabilizing the injury in all cases of abdominal trauma rapid assessment stabilization and transport to a Trauma Center are Paramount to Patient survival"
    },
    {
        "Advances in Trauma Care": "trauma introduction trauma in the context of medical emergencies poses a significant threat to life necessitating Swift and precise actions for optimal patient outcomes the first aspect in managing trauma cases is the emphasis on the rapid identification of injuries and the subsequent transport of patients to an appropriate Trauma Center where they can receive definitive care this initial step is vital as the severity of trauma injuries can range widely from minor to life-threatening therefore a comprehensive trauma assessment is essential in all cases to accurately evaluate the extent of injuries ensuring that each patient receives the most appropriate care in instances where injuries are minor a local hospital can effectively treat them however identifying life-threatening illnesses and injuries has greatly improved patient outcomes this underscores the importance of skilled Health Care Professionals in the prehospital setting who must prioritize several key steps firstly ensuring seen safety is principal to protecting both patients and responders secondly rapid immobilization and stabilization of trauma patients help prevent further harm and stabilize their condition finally efficient transport to a Trauma Center is needed for patients requiring definitive care when dealing with scenarios involving trauma patients there are two primary situations to consider first the seam call scenario involves the critical care transport professional providing Advanced life support or basic life support back up at the scene of the incident second in a transfer call scenario the critical care transport professional plays a pivotal role in safely transferring a critically injured patient to a Trauma Center during this phase the provider has access to vital resources including Labs reports Imaging Physicians and even other healthc Care staff facilitating seamless continuity of care balancing the time needed to stabilize a patient's condition for transport against the urgency of transporting an unstable patient immediately for definitive care is a delicate decision that healthc care providers must make each case requires careful consideration to optimize the patient's chances of recovery when discussing morbidity and mortality in the context of trauma these terms are often used interchangeably with disability and death morbidity refers to non-fatal injuries and disabilities resulting from trauma while mortality encompasses deaths caused by injuries and diseases it is worth noting that trauma is the leading cause of death in the Pediatric population and Remains the leading cause of death overall to reduce the impact of trauma prevention measures and the provision vision of highquality trauma care are essential in the context of traumatic injuries debilitating conditions are commonly observed in motor vehicle crashes or mvcs avoiding secondary injury to the patient during and after the initial trauma is critical in ensuring the best possible outcome for the patient this emphasizes the importance of comprehensive trauma care from initial assessment to ongoing treatment and",
        "Overview of Trauma Rehabilitation": "overview of trauma Newton's Laws of Motion are fundamental principles in physics that play a decisive role in understanding the Dynamics of objects and their behavior when forces are applied to them Newton's first law also known as the law of inertia states that a body in motion remains in Motion in a straight line unless acted upon by an outside force this law helps predict injury patterns in trauma cases for example understanding that an unrestrained occupant in a moving vehicle will continue moving at the same speed and direction unless a force such as a collision or sudden de acceleration is applied is essential for anticipating potential injuries Newton's Second Law often expressed as FAL ma states that Force equals mass time acceleration this deals with an object's behavior when an outside force is applied this law helps explain how an object accelerates when subject to a force acceleration depends on two two key variables the mass of the object and the force acting on it if you apply a greater force to an object its acceleration will increase and if you increase the mass of an object the acceleration will decrease this concept is relevant when assessing patients who have experienced trauma understanding the relationship between force Mass and acceleration is essential for evaluating the extent of injuries and predicting how patients bodies responded to external forces Newton's third law states that to every action there is an equal and opposite reaction this law is particularly valuable when evaluating the mechanism of injury and predicting injury patterns in the context of critical care transport it helps healthare Care Professionals understand how a patient's body may have reacted to the forces involved in an accident or trauma by analyzing the equal and opposite reactions resulting from forces providers can better assess the predictability of injuries and provide appropriate care based on the specific mechanism of injury experienced by the patient overall Newton's Laws of Motion provide a solid foundation for understanding the physics of traumatic events and their effects on the human body traumatic injuries in the medical field are typically categorized into two primary classifications blunt and penetrating it is important to note that patients May sometimes present with injuries that fall into both these categories simultaneously blunt injuries result from the exchange of energy between an object and the body without any intrusion through the skin these injuries often occur during incidents involving rapid de accelerations such as collisions in motor vehicle accidents or rapid vertical de accelerations like Falls from Heights blunt injuries can also occur when energy is transferred from blunt instruments such as being struck by a stick or a baseball bat these injuries may lead to a range of trauma including contusions fractures and internal injuries all of which can vary in severity on the other hand penetrating injuries are caused by external forces that result in the tissue being penetrated by an object common examples of objects that can cause penetrating injuries include projectiles like bullets and knives fragments from explosions or when individuals fall onto fixed objects penetrating injuries can lead to damage to vital structures within the body and often require immediate medical attention due to the risk of severe bleeding organ damage or infection de acceleration injuries occur as a result of the sudden stop of the body's forward motion and can be attributed to various causes such as Falls automobile crashes or even instances of abuse as seen in Shak and baby syndrome these injuries often lead to trauma involving body organs fascia nerves and other soft tissues which can manifest as shearing auling or rupturing of these structures for instance in a motor vehicle collision Vision a passenger's body can come to an abrupt halt when the vehicle stops suddenly causing internal organs to continue moving momentarily resulting in shearing or tearing of tissues external Force injuries on the other hand are caused by forces that disrupt or damage body tissues typically stemming from events like gunshot wounds stabbings or projectile impacts the severity of these injuries depends on several factors including the specific anatomic area involved the mass of the object responsible for the injury and its velocity upon impact kinetic energy which is the energy associated with an object in motion plays a significant role in these injuries and is calculated using the Formula 1 12 of the masstimes Velocity squared providers must possess excellent patient assessment skills to accurately prioritize a patient's injuries and determine the most appropriate treatments tunnel vision should be avoided as it ensures a comprehensive assessment of all injuries and helps prevent overlooking critical issues that may not be immediately apparent this broad understanding of De acceleration and external Force injuries is essential for Effective trauma management and the provision of Optimal Care to",
        "Trauma Scoring Systems": "patients trauma scoring systems scoring systems assess trauma patients and provide indicators of their survivability making them invaluable tools for regional Trauma Centers in conjunction with quality assurance programs one such scoring system is the Glascow Coma Scale or GCS primarily used to assess neurologic function in trauma patients the GCS determines a patient's level of Consciousness by measuring and assigning scores for eye opening verbal response and motor response scores on the GCS range from a highest possible score of 15 indicating full ious to a lower score of three which reflects deep unconsciousness this scale is not limited to trauma cases and is also utilized to assess patients with medical conditions like drug overdose metabolic disorders or neurologic emergencies a GCS score below 8 often necessitates intubation or other Advanced Airway management techniques highlighting its significance in identifying patients in need of immediate intervention moreover it is essential for healthc Care Professionals to provide detailed explanations of abnormal GCS findings in the narrative section of the patient care record with frequent assessments as often as every 5 minutes and comparisons to bason scores to monitor changes accurately another scoring system the trauma score serves as a predictor of a patient's likelihood of survival this score which ranges from 1 to 16 with 16 being the best takes into account various factors including the GCS score respiratory rate respiratory expansion systolic blood pressure and capillary refill time it provides valuable information to healthc care providers regarding a patient's overall condition and helps in triaging and determining the urgency of interventions however it's important to note that the trauma score May not accurately predict survivability in patients with severe head injuries as such cases often involve complex factors beyond what the trauma score encompasses therefore while scoring systems like the GCS and the trauma score are valuable tools assessing trauma patients clinical judgment and comprehensive understanding of the individual patients condition remain important in providing the best possible care the Revis trauma score or RTS is one of the most commonly used scoring systems in the medical field for assessing the severity of injury in trauma patients it evaluates three key physiologic parameters respiratory rate blood pressure and the GCS the score typically ranges from 0 to 13 with more seriously injured patients receiving lower scores to provide a weighted assessment the scores are converted into values ranging from 1 to 7.8 408 with the GCS score receiving greater importance in the calculation while this is Impractical for field use due to its complexity it does serve as a valuable research tool in studying trauma outcomes one limitation of the RTS is its inability to readily identify a small percentage of severely injured trauma patients whose vital signs do not accurately represent their true condition this can occur because compensatory mechanisms or the early stages of shock May mask the severity of injuries therefore regardless of the RTS score providers must always be prepared for a trauma patient's condition to deteriorate over time as the true extent of injuries may become more apparent another scoring system the abbreviated injury scale or AIS focuses on assessing the anatomic severity of injuries and is designed to rank their severity reasonably accurately the AIS categorizes injuries into six body regions which include the head neck thorax abdomen spine and extremities each injury within these regions is assigned an individual score on a scale of 1 to six with higher scores indicating more severe injuries the AIS distinguishes injuries as minor with a score of one moderate with a score of two serious with a score of three severe with a score of four Critical with a score of five or unsurvivable with a score of six there is one limitation in that this system does not account for injuries involving multiple body systems potentially underestimating the overall severity of such cases the injury severity score or ISS is an anatomic scoring system that provides an overall assessment of patients who have sustained multiple injuries this scoring system quantifies multi-stem injuries by utilizing the AIS scores the ISS calculates a patient score by adding the squares of the highest AIS scores in the three most most severely injured body systems this results in an ISS score ranging from 1 to 75 with lower scores indicating minor injuries and higher scores signifying injuries with a high mortality rate in cases where any body region assigned an AIS score of six the ISS score is capped at 75 trauma registry Personnel commonly use the ISS for data collection and research purposes as it provides a standardized way to assess injury severity and track outcomes patients with an ISS greater than 15 are typically considered major trauma patients and they are often transferred to a level one trauma facility for Specialized Care due to the severity and complexity of their injuries additionally the trauma ISS or Tris is another scoring system that calculates the survival probability of critically ill or injured patients it combines the results of the ISS and the revised trauma score along with the patient's age to estimate the likelihood of survival while Tris is a valuable tool for risk assessment and outcome prediction it is rarely used in the transport setting as it is typically employed in more clinical and research focused context where comprehensive data and extensive patient information are readily available for analysis and",
        "The Hypothermia-Acidosis-Coagulopathy Triad": "calculation the hypothermia acidosis coagulopathy Triad the lethal Triad consisting of hypothermia acidosis and coagulopathy represent a critical and in interconnected set of medical conditions that can have severe consequences especially in trauma patients each element of this Triad exacerbates the effects of the other two leading to a vicious cycle that can accelerate patient decompensation and negatively impact outcomes hypothermia is a condition with rates in trauma as high as 50% and it can result from various factors including the injury itself which leads to a loss of blood and disrupts the body's Thermo regulation mechanisms environmental factors such as exposure to cold weather or inadequate temperature control during Transportation can also contribute to hypothermia failure to warm infusing fluids during treatment is another potential cause providers address hypothermia by actively working to reverse or prevent it through measures such as providing external warming using heated blankets and ensuring the infusion of warm fluids acidosis characterized by an abnormal decrease in blood pH can be brought on by various factors including extreme hypothermia and the administration of large volumes of acidic crystalloid Solutions like normal saline to prevent acidosis Healthcare professionals often prefer using Solutions like plasma light a and plasma light 148 for large volume resuscitation as they are less acidic adequate ventilation to maintain appropriate oxygen in carbon dioxide levels is also essential to avoid hypoventilation and subsequent acidosis coagulopathy the third component of this lethal Triad is observed in about 25% of severely injured patients it can be precipitated by hypothermia acidosis and acute blood loss to reverse or prevent coagulopathy early replacement of both clotting factors and packed red blood cells is critical new recommendations emphasize the use of a one to one:1 ratio of plasma platelets and packed red blood cells in in transfusion therapy minimizing the use of crystalloid infusions to maintain hemostasis and reduce the risk of coagulopathic complications by addressing each element of the lethal Triad promptly and effectively providers can improve patient outcomes and minimize the risks associated with these life-threatening conditions in trauma",
        "Diagnostic Imaging for Trauma": "patients Diagnostic Imaging for trauma obtaining an understanding Imaging studies related to trauma is a component of the trauma care Paradigm for critical care transport professionals Imaging studies serve as valuable AIDS in managing and directing further care for trauma patients offering insights into the patient's condition they also help confirm the effectiveness of previous care interventions such as endot tral 2be placement and the positioning of invasive catheters standard radioraps are an essential part of the initial assessment of trauma patients as they are typically used to verify the structure in landmarks ensuring proper size and placement of anatomic structures or medical devices they also assess the symmetry of structures and identify foreign objects that may be present computed tomography or CT scans are commonly used in trauma cases to provide detailed information for various purposes they are particularly valuable for identifying head injuries pinpointing sources of bleeding and evaluating complex fractures typical CT studies involve scanning areas such as the head spine chest and abdominal pelvic Reg the interpretation of CT scans is somewhat similar to that of plain x-rays as it involves assessing the structure and integrity of anatomical components detecting abnormalities and guiding further clinical decisions ultrasonography is a valuable diagnostic tool in the realm of traumacare as it includes various Tech techniques that offer critical insights into the patient's condition one such technique is the focused assessment with sonography for trauma or fast which involves using ultrasound to identify the presence of pericardial or intraperitonial free fluids fast has been widely adopted by practitioners who perform point of care ultrasounds in trauma settings and is largely replaced diagn tic Paro Lage reducing the need for exploratory lipectomy an extended fast or east examination can reliably identify thoracic injuries like pneumothorax and hemothorax however it is important to note that fast has its limitations as it does not directly evaluate for solid organ injury but rather looks for signs of accumulated bleeding additionally it does not assess the retroperitoneal space and does not identify the specific type of fluid detected nonetheless some Transport Services have adopted fast for use in the prehospital setting where it shows promise in early identification of abdominal bleeding in trauma patients trans thoracic echocardiography and trans esophageal e cardiography or te are Advanced ultrasound techniques that play critical roles in the assessment of critically ill or injured patients te enables professionals to use focused exam algorithms such as heart scan fate feel fear and bleep to rapidly determine cardiac pathology in these patients on the other hand it is also Al revolutionized intraoperative cardiac monitoring by involving the insertion of a probe into the esophagus to provide realtime evaluation of cardiac function and fluid volume status during surgery these techniques are invaluable for assessing and managing critically ill or injured patients allowing for prompt and targeted interventions based on the diagnostic information that they provide magnetic resonance imaging or MRI is another tool used in trauma to identify abnormalities and provide detailed Imaging of various body structures however its utility in major trauma cases may be limited by factors such as availability and the time required to obtain images while MRI offers exceptional soft tissue contrast and can help help assess internal injuries its use in trauma patients should be carefully considered based on the clinical situation and the need for timely interventions intraabdominal pressure or IAP monitoring is a critical aspect of trauma care as elevated intraabdominal pressure can have deleterious effects potentially leading to abdominal compartment syndrome or ACS and if left untreated death ACS plays a significant role in inorgan damage and the development of multi-stem organ failure in critically ill patients it can be measured using a variety of commercial devices or user assembled equipment Often by following specific steps to measure it via a urinary catheter there are specific definitions related to IAP and AC C CS intraabdominal hypertension is characterized by sustained IAP greater than 12 millimet of mercury while ACS is diagnosed when there a sustained IAP greater than 20 millimeters of mercury which is often associated with new onset single or even multi-organ system failure there are three types of ACS primary secondary and recurrent primary ACS typically arises from surgical interventions or injuries in the abdominal pelvic region secondary results from conditions outside the abdomen such as sepsis or Burns recurrent ACS occurs when there is a recurrence of ACS following initially successful surgical or medical treatment of primary or secondary ACS preventing and treating ACS are components of trauma care and prevention involves careful monitoring of IAP and targeted medical management in cases where ACS does develop or is at risk of developing surgical decompression may be necessary to relieve the increased pressure within the",
        "Thoracic Trauma": "compartment thoracic trauma injuries are a significant concern in the field of TR Trum care is highlighted by statistics from the CDC approximately onethird of trauma related deaths in the United States are attributed to thoracic trauma with one in four trauma deaths directly associated with thoracic injuries it is noteworthy that only 15 to 20% of these potentially catastrophic injuries necessitate open chest surgery while the majority can be effectively managed with relatively simple interventions within the scope of critical care transport professionals the anatomy of the thorax is a critical consideration in understanding thoracic injuries the cavity comprises a bony cage consisting of 12 pairs of ribs that articulate anteriorly with the sternum and posteriorly with a thoracic spine within the cavity there are two compartments each housing a lung the mediastinum is centrally located between these two cavities and contains vital structures such as the heart Superior and inferior vena aorta bronchi trachea and esophagus separating the chest and abdominal cavities is the diaphragm which inserts into the thoracic cage below the fifth rib the primary function of the thorax is to facilitate adequate quit oxygenation and circulation injuries to this region can result from both blunt and penetrating mechanisms with approximately half of all chest injuries involving the chest wall the integrity and proper function of the ribs diaphragm and plural membrane help maintain the changes in pressure required for Effective ventilation pneumothorax is a common condition in the context of chest trauma and can present in two primary forms open or closed it is reported in a significant proportion of chest injuries ranging from 15 to 50% of cases an open pnea thorax also known as a sucking chest wound occurs when there is a defect in the chest wall allowing air to enter the thoracic space this disrupts the normal adherence between the plora and leads to lung collapse typically open Numan thorax results from a penetrating chest injury and has a distinctive clinical feature where air is drawn into the thoracic cavity with each breath causing hypoxia due to impaired lung function differential diagnosis for respiratory distress and chest trauma allows for Effective patient management it includes conditions Beyond Simple pneumothorax such as tension pneumothorax flail chest hemothorax tracho bronchial injury and Pulmonary contusion accurate differentiation among these conditions is essential in order to provide appropriate And Timely interventions open pneumothorax is a medical emergency that requires prompt recognition and intervention to manage open numat thorax effectively certain equipment is essential including appropriate personal protective equipment to ensure the safety of the medical team an inclusive dressing and medical tape for sealing the wound indications for addressing open pnea thorax include the emergency relief of disia secondary to this condition however it is important to note that an open num thorax and tension num thorax are two distinct entities and addressing an open pneumothorax is contraindicated in cases of tension pneumothorax open pneumothorax can lead to complications the most critical of which is the development of attention numat thorax where air accumulates within the thoracic cavity leading to increased pressure and further compression of the lung in mediastinal structure signs and symptoms of an open Numa thorax typically include penetrating chest trauma with a characteristic sucking sound often referred to as a sucking chest wound patients may experience difficulty breathing and Topia in terms of Transport management providers must follow specific steps to address open numat thorax first Main maintain an open Airway and administer appropriate oxygen therapy to support respiratory function immediately close the chest wound initially using a gloved hand to apply direct pressure over the wound to prevent air from entering apply an occlusive dressing which should be taped down on three or four sides to create an airtight seal this dressing prevents the Ingress of additional air into the thoracic cavity continuously monitor oxygen saturation Vital Signs and the cardiac monitor to assess the patient's response and condition be vigilant for the development of tension numo thorax or any signs of an inadequate seal which may necessitate needle decompression or assisted ventilation if permitted by protocol consider inserting a chest to tube or pigtail catheter for further management lastly continuously monitor the chest to drainage system through transport to assess for any changes or complications tension in a thorax is a life-threatening condition that results from the continual influx of air into the plural space leading to increased pressure within the thoracic cavity it can occur secondary to various causes including closed simple pneumothorax or after sealing an open num thorax common signs and symptoms include trouble breathing anxiety jvd rapid breathing tracho deviation trach tugging during inspiration decreased ventilatory compliance when bagging and increasing Peak inspiratory pressure or peak airway pressure especially if the patient is on a ventilator diminished or absent breath sounds on the affected side may be present particularly if the numat thorax is significant other clinical findings can include pulus paradoxes electrical alterans and elevated Central Venus pressure effective management require specific equipment including appropriate PPE such as sterile gloves additionally providers will need a 14 gauge or larger IV catheter the minimum should be 3.25 in or 8 cm in length additionally a 10 mL syringe with 1 to 2 MLS of sterile saline to visualize bubbling air escaping as it can be difficult to hear in many cases 2% chlorohexidine for skin preparation and an optional flutter valve such as the heck a non-lubricated condom or a glove finger sterile dressings are also important for wound care indications for addressing tension Numa thorax involve the emergency relief of this life-threatening condition however providers must avoid unnecessary intervention in patients without signs of tension numat thorax remember diminished breast sounds alone don't specifically mean that the patient has attention in a thorax and the lung must be between 30 to 40% collapsed before there is typically a noticeable difference transport management necessitates immediate needle decompression if the protocol allows consideration should be given to inserting a chest tube to further manage the condition if a chest tube is placed it should be maintained on suction during transport to ensure the continued removal of air and reexpansion of the affected lung hemothorax is characterized by the presence of blood in the plural space the plural space can accommodate a certain volume of fluid with each body cavity capable of holding up to 3,000 MLS of blood when the accumulation of blood within this space reaches a significant volume is classified as massive hemothorax typically involving around 1500 MLS of blood hemothorax can be a serious condition as it can lead to hypemic shock as well as interfere with lung function and compromise oxygenation various factors can lead to hemothorax including both penetrating and blunt trauma to the chest as well as some underlying medical conditions like tumors clinical signs and symptoms associated with this include hypoxia agitation hypotension tachicardia Topia decreased breath sounds on the affected side dullness to percussion hemo typis worsening signs of shock and falling Central Venus pressure typically the management of a hemothorax is primarily supportive and includes the following steps first maintain an open Airway and provide appropriate oxygen therapy to ensure adequate oxygenation and ventilation in the field immediate transport to a medical facility is needed for further evaluation in treatment initiate IV fluid administration to address potential hypohemia however providers should exercise caution when administering fluids as raising blood pressure above specific thresholds such as 90 mm of mercury systolic or 65 mm of mercury for a mean arterial pressure may increase blood loss or dislodge clots potentially restarting or worsening bleeding be vigilant of the development of attention Numa thorax consider the insertion of a chest tube or pigtail if your medical protocol permits this procedure can help drain the accumulated blood and facilitate reexpansion of the lung and lastly if a chest tube is placed it should be maintained on suction during transport to ensure effective drainage of the hemothorax chest tubes are utilized to remove air fluid or pus that has accumulated within the plural cavity restoring proper lung function and alleviating potentially life-threatening conditions while chest tube placement may be performed by some Critical Care transport Professionals in certain Health Care Systems all providers should be prepared to care for and transport patients who have chest tubes in place to perform a chest tube insertion providers must have the appropriate equipment on hand this includes essential protective equipment such as sterile gloves to ensure aseptic techniques during the procedure other equipment includes a scalpel for creating an incision a sterile chest tube with a size typically ranging from 28 to 36 French Kelly clamps both curved and straight for tissue handling sterile occlusive dressing to secure the tube suing material to close the incision 2% chlorohexidine for skin prep and local anesthetic if the patient is awake a vital component of chest tube insertion is the use of a fluid collection device equipped with the one-way valve this device allows for the controlled relas release of air fluid or pus from the chest cavity while preventing re-entry alternatively an indwelling catheter bag with a one-way valve may be employed for this purpose tape is used to secure the tube in dressing in place while mechanical suction devices may be added if necessary in order to Aid in the removal of plural contents indications for chest tu insertion Encompass various conditions including pum thorax hemothorax and Emma which is the presence of infected pus within the plural space in each of these situations the chest tube is a tool for draining and managing the accumulated contents ultimately facilitating lung reexpansion and restoring respiratory function chest tube insertion can be associated with several potential complications and providers need to be aware of these complications in order to take appropriate measures to mitigate them we'll look at a few of the potential complications now recurrent PNE numores despite the insertion of a chest tube some patients May experient recurrent PNE numores necessitating further intervention or evaluation ACC accidental removal chest tubes can be accidentally dislodged or removed which will require reinsertion or alternative management broken collection chamber The Collection chamber of the drainage system can become damaged or broken potentially compromising the ability to Monitor and manage plural drainage effectively paranal injury during the insertion of a chest tube there is a risk of unintentional injury to to the lung tissue or panma which can lead to bleeding or other complications laceration of intercostal vessels these vessels located between the ribs can be inadvertently lacerated during the chest tube insertion procedure resulting in bleeding creation of a hemothorax or bleeding in rare cases the chest tube insertion process itself can lead to the creation of a hemor or simply exacerbate bleeding within the plural cavity misplacement below the diaphragm improper placement of the chest tube such as inserting it above the diaphragm can result in inadequate drainage or complications related to abdominal structures lastly there is always a risk of infection associated with invasive procedures like chest tube insertion and strict aseptic techniques should minim minimize this risk providers should be trained to handle these potential complications appropriately and seek medical guidance or intervention as needed in terms of Transport management following chest tube insertion there are several key considerations first ensure all connections are securely taped or banded with wire to prevent accidental separation during transport maintain a secure ly taped an occlusive dressing over the insertion site Mark the depth of the tube with a felt temp marker and secure it with sutures wire or additional tape to prevent accidental dislodgment keep the drainage unit positioned below the level of the chest at all times during transport to facilitate effective drainage if the chest tube is attached to a suction device assess whether the patient can tolerate discontinuing the vacuum vum during transport if not attach the chest tube to a portable suction as needed Coil Tubing to prevent Kinks or dependent Loops ensuring a continuous and unobstructed flow of fluids Monitor and document important parameters including bubbling in the water seal the type and quantity of output in the collection chamber and any changes in the patient's condition do not clamp chest tubes during transport as this may increase the risk of tension in with thorax or compromise effective drainage lastly continuous bubbling in the Water Seal chamber May indicate a tracho bronchial injury which obviously should be promply addressed the pigtail catheter is a small board tube typically ranging inze size from 6 to 12 French and it is inserted into the plural cavity using a seldinger technique often with the assistance of ultrasound guidance for precise placement this minimally invasive approach offers several advantages over larger boore chest tubes pigtail catheters are associated with less pain during insertion produce less scarring and do not require extensive tissue dissection or skin closure when removed additionally they carry a lower risk of complications compared to their larger counterparts in some healthc care settings and regions the use of these catheters may be included in the scope of practice for the critical care transport professional to successfully perform this procedure providers must have the appropriate equipment on hand this includes udes PPE an ultrasound unit scalpel catheter sterile elusive dressing suturing material 2% chlorohexidine a local anesthetic if the patient is awake during the procedure and a fluid collection device a flail chest is characterized by fractures in two or more places to two or more adjacent ribs and we often refer to it as a flail segment this condition is relatively common accounting for approximately onethird of serious chest injuries and can result from blunt force trauma this condition may not be immediately apparent and can go undetected for up to 6 hours the Hallmark of a flail chest is is the paradoxical movement of the affected segment relative to the rest of the chest wall while the chest wall moves during breathing the flail segment remains stationary this condition can lead to pulmonary or myocardial contusion which represents one of the most dangerous consequences of the flail chest these patients typically present with a range of signs and symptoms including severe pain trouble breathing decreased breath sounds on the affected side tenderness crepitus and bruising over the injured area management includes maintaining an open Airway and applying appropriate oxygen therapy if necessary ventilation assistance with CPAP may be initiated and intubation may be required in addition to addressing the flail chest providers should be vigilant for the development of complications such as attention in a thorax hemothorax or respiratory failure secondary to pulmonary contusion the gold standard for flil chess is positive pressure ventilation which may involve internal fixation with a sedated patient who has been adequately treated for pain paracardial tanod is another life-threatening condition related to thoracic trauma it occurs when there is an abnormal accumulation of blood or fluid within the pericardium this accumulation can compress the ventricles of the heart leading to compromised cardiac filling and output paracardial tanod can result from various causes including trauma infections myocardial infarction and heart surgery signs and symptoms include be Triad which is a narrowing pulse pressure jvd and muffled heart tones paradoxical puls electrical alterans Progressive decreases in ECG voltage hypotension cyanosis trouble breathing tachicardia pea a rising Central fenus pressure and widened media stum on a chest x-ray the management of paracardial tanod involves an emergency procedure known as paracardial centesis providers should be equipped with the necessary materials including sterile gloves a paracardial synthesis kit with a mansfi catheter cardiac Monitor and defibrillator syringes medications pigtail catheter drapes a spinal needle stop coock alligator clip scalpel and sterile dressings in some cases ultrasound imaging may be available to Aid in the procedure indications include chest trauma with a patient in extremis such as experiencing pulses electrical activity or positive findings on a focused assessment with sonography for trauma exam that shows pericardial blood in conjunction with clinical signs contraindications include the absence of demonstratable paracardial effusion severe thrombocytopenia non-correctable coagulopathy or active skin or soft tissue infection at the proposed needle insertion site except in critical patients complications associated with pericardial centesis can be serious and include ventricular arrhythmias ventricular or atrial puncture laceration of coronary arteries or lung paracardial tamponade for myocardial laceration air embolism acute pulmonary edema or injury to nearby organs such as the liver or stomach the paracardial window is a surgical procedure performed to relieve paracardial tampeno this procedure is typically performed in a healthcare facility and involves making an incision in the skin just inferior to the zyo process and dissecting down to the surface of the pericardium the pericardium is then enzed allowing the accumulated fluid to drain a drain is placed through the dissection tract into the pericardium to facilitate continued drainage the role of a critical care transport provider in managing a patient with a paracardial window involves initially assessment and monitoring upon initial contact the provider should note the quality and color of drainage from the paracardial window as well as the volume of drain output monitoring for post-procedural complications such as arhythmia or recurrence of tamponade is also important aortic dissection or transsection is a severe and often fatal injury that can occur as a result of De accelerating forces and sheer forces commonly associated with motor vehicle collisions the injury usually involves the aorta which is injured at the ligamentum arteriosum tears in the ascending aorta are almost uniformly fatal while patients with tears on the descending side have a 15% chance of survival until they reach the operating room with a 30% mortality rate in the hospital diagnosing aortic dissection or transsection can be challenging especially in the prehospital setting careful evaluation of the mechanism of injury is essential to assess the likelihood of said injury signs and symptoms that may raise suspicion of aortic injury include a pulse deficit or blood pressure difference between the arms hypotension a decreased level of Consciousness hypertension in the upper extremities decreased pulse amplitude in the lower extremities chest pain chest ball bruising and x-ray findings of a widen media stum with blurring of the aortic knob and fractures of the first and second ribs in the transport management of a patient with suspected aortic dissection or transsection the provider should prioritize maintaining an open Airway and providing appropriate oxygen therapy ventilation patient assistance and intubation are almost always necessary IV fluids should be initiated but beta blockers should be administered to maintain a mean arterial pressure of 65 to 70 millim of mercury and fluids should be withheld if possible myocardial contusion is an injury primarily resulting from blunt force to the anterior chest wall often associated with mvcs the the extent of damage can vary widely patients with myocardial contusion may present with symptoms such as chest pain palpitations arrhythmias ST segment elevation bundle branch blocks especially on the right side Atri ventricular blocks cardiac murmurs pericardial friction rub persistent tacac cardia without other apparent causes and sometimes even cardiogenic shock management of myocardial contusion involves providing appropriate oxygen therapy and pharmacologic treatment for rhythmia the patient should be closely monitored for the development of complications such as hemopericardium which can lead to pericardial tampen myocardial rupture or simply ventricular aneurysm early recognition and intervention are critical in managing myocardial contusions diaphragmatic rupture is a condition that can be caused by both blunt and penetrating trauma blunt compression of the abdomen can lead to a large rupture in the diaphragm resulting in the herniation of abdominal organs into the thoracic cavity patients with this condition may present with signs and symptoms such as chest or abdominal pain acute respiratory distress decreased breath sounds abdominal sounds heard in the chest cavity subcutaneous enyma and obvious signs of penetration in the abdomen in the transport management of these patients it is essential to assist ventilation as needed and administer appropriate oxygen therapy in some cases medical control May advise the insertion of a nasogastric or orogastric tube to decompress the stomach which can help alleviate symptoms and reduce the risk of further complications trob bronchial disruption is a relatively rare but life-threatening injury that can be caused by both blunt and penetrating trauma penetrating injuries are more commonly associated with this condition tracho bronchial disruptions often occur within 1.5 in of the Corina but can happen anywhere along the tracho bronchial tree signs and symptoms may include severe respiratory distress hypoxia tachicardia subcutaneous empyema hemo typis jvd trial deviation and continuous air leak after the placement of a chest tube in the transport management of these patients providers should administer appropriate oxygen therapy and provide positive pressure ventilation unless it worsens the patient's condition in some cases needle decompression may be necessary to alleviate tension within the thoracic cavity additionally if indicated and within protocols a chest tube or pigtail catheter may need to be inserted rarely patients may require multiple chest tubes in cases of very proximal bronchial injury pulmonary contusion is a condition characterize by tearing and lacerations to lung tissue leading to bleeding and the leakage of plasma into the alv and the interstial spaces around them this injury occurs when the lung hits the inside of the chest wall due to a shearing Force commonly associated with blunt trauma initially patients with pulmonary contusions may not exhibit significant signs and symptoms but over hours to days they may experience increasing hypoxia opacity in the area of chest wall damage on an X-ray and increased difficulty ventilating as fluid accumulates in the lungs due to inflammation in the transport management of these patients it is essential to provide ventilatory support this can be achieved through pressure control ventilation or other intermittent mandatory ventilation techniques along with positive end expiratory pressure of 10 to 15 cm of H2O alternatively non-invasive ventilation may be considered based on the patient's condition adequate analgesia should also be provided to alleviate pain and discomfort associated with this condition esophageal perforation is a condition characterized by a tear or hole in the esophageal wall this condition can have various causes with penetrating injuries being a common factor penetrating injuries leading to esophageal perforation may result from projectiles or CTIC ingestion additionally medical conditions such as cancer or erosions from gastro esophageal reflux disease can contribute to the development of esophageal perforation excessive vomiting may also cause a malerie wise tear signs and symptoms typically include pain fever dysphasia subcutaneous air in the neck neck stiffness pic type pain evidence of free mediastinal air or widening on Imaging studing and a crunching sound on oscilation transport management of a patient with esophageal perforation involves monitoring the ABCs and providing support for physiologic parameters as indicated it is important not to insert a nasogastric tube in such cases and if one is already in place it should not be removed traumatic aixia is a condition resulting from severe sudden crushing injuries to the chest and abdomen it occurs when forces applied to the body cause blood to be pushed backward out of the right side of the heart leading to engorgement of the veins in the chest neck and head this phenomenon gives the chest neck and head a blue or purple appearance resembling extreme cyanosis signs and symptoms include blue or color discoloration of the chest neck and head often accompanied by Associated injuries at the sight of the crush injury other manifest stations include jvd conjunctival petii and a sharp line of demarcation between the discolored skin and normal skin color below it during transport supportive care is provided to address the patient's overall condition and Associated injuries should be treated accordingly if the patient is found ENT trapped providers must establish IV access and develop a treatment plan to address sudden hypotension and the potential release of substances such as myoglobin and potassium when the patient is",
        "Facial Trauma": "extricated facial trauma Airway compromise can be a life-threatening situation that arises due to various factors including obstruction or injury to the airway it can lead to a severe reduction in the flow of air into and out of the lungs resulting in hypoxia and potentially fatal consequences Airway compromise is a critical concern for healthc care providers as it affects the patients ability to breathe which is essential for oxygenation and maintaining vital functions providers must manage the situation properly and effectively to ensure the patient safety and prevent further deterioration additionally Airway compromise can have significant implication for patients in terms of their social interactions and self-image as it can impact their ability to communicate and perform daily activities providers must also manage their emotional responses when dealing with patients experiencing Airway compromise as remaining calm and focused in order to provide appropriate care ear injuries while not typically within the primary focus of critical care transport providers can still present in trauma cases and require attention one category of ear injury is external ear injury which is considered a local injury with no immediate systemic implications the standard approach to solve tissue injuries applies in these cases however when there is leaking blood or fluid from the auditory canal it may indicate a more serious injury to to assess the severity healthc care providers can perform a Halo test which involves applying exteral dressing and observing any fluid or blood that may accumulate around the ear any significant findings should prompt further evaluation and intervention another type of ear injury involves a ruptured tanic membrane this can result from various causes including over pressure injuries such as explosions or direct blows to the ear it can also occur due to failure to equalize middle ear pressure during activities like scuba diving most ruptured tanic membranes will heal spontaneously but they can be associated with pain vertigo vomiting invisible blood in the ear canal in cases of a ruptured tanic membrane transport management involves applying external dressing to protect the ear without packing the ear canal and administering anti-emetics if necessary to alleviate symptoms such as nausea and vomiting eye injuries while often dramatic are generally not life-threatening but they do require careful assessment and management by healthc care providers in many cases Critical Care transport providers can do little more than protect the injured eye from further harm and ensure the Safe Transportation of the patient to an Opthalmology service for Specialized Care however there are exceptions such as chemical burns to the eye which demand immediate and intensive intervention eyelid lacerations are one type of eye injury that providers May encounter when faced with such an injury it is important to apply direct pressure in a manner that avoids pushing on the globe of the eye additionally C C applications may help reduce swelling but Health Care Providers should be vigilant for any Associated Eye injuries that may have occurred conjunctival and corneal injuries can be quite serious especially when they involve shrapnel from high-speed equipment or impalement in cases where an object is implanted in the eye any movement of the eye or the object should be prevented during transport to protect the unaffected eye Healthcare Providers May patch it hyphema is another eye injury characterized by collection of blood in the anterior chamber of the eye typically resulting from blunt trauma or underlying medical conditions signs and symptoms may include a patient's complaint of reduced vision and the presence of a pool of blood in the eye which can be visualized directly or by shining a pin light obliquely at the globe hyphema is often graded on a scale from 1 to four with grade four indicating total clotted blood during transport both eyes should be patched and the patient should be positioned as upright as possible analgesics can be administered to manage pain and it's important to avoid antiplatelet agents in cases of severe anxiety an exiotic may be necessary to facilitate the patient's transportation ocular Globe rupture is a serious eye injury that can result from either penetration with the foreign body or blunt trauma to the eye this injury can present with various signs and symptoms including a penetrating lid injury Bolis conjunctival Hemorrhage the presence of blood in the anterior chamber a peaked or deformed pupil lens disloc location vitous Hemorrhage and decreased visual Acuity when managing a patient with an ocular Globe rupture during transport providers should protect the affected eye using a rigid Eye shield or cup additionally anti-ds and pain medication may be administered as needed and an anti-tussive may be administered to prevent increased intraocular pressure resulting from coughing ocular evulsion on the other hand involves the complete enucleation of the eyeball from the eye socket the primary goal during transport is to protect the eye from further trauma which can be achieved by using a protective cup or other rigid protective device with Galls padding traumatic retinal detachment refers to the separation of the inner layers of the retina from the pigmented epithelium patients with this condition may experience sensations of flashing light often accompanied by a shower of floaters and vision loss some may describe black spots particularly in the center of their visual field or a spiderweb like vision during transport avoid any pressure on the globe and protect the eye using a rigid metal Eye shield m fractures and dislocations can result from various traumatic incidents and often present with specific signs and symptoms including crepitus trismus swelling and a patient complaint that their jaw doesn't feel right indicating malocclusion when managing a patient with a mandibular fracture or dislocation during transport it's important to be prepared for potential Airway issues having wire cutters available is important in case the patient's jaw is wired shut an emergency Airway access is needed additionally being skilled in naso tracheal intubation and having the necessary equipment on hand is important for addressing any Airway challenges that may arise Dental evulsion the complete displacement of a tooth from its socket has a good chance of successful reimplantation if done within an hour of the injury the American Dental Association provides specific guidelines for the proper handling and transport of A's teeth never place an Evol tooth in any substance that can dry or crush the tooth's exterior gentle handling of the tooth is vital avoiding rough treatment or rinsing rubbing scraping or disinfecting the outside of the tooth instead it should be placed in a soft transport device Dev preferably in Hanks solution if this is not available whole milk is a suitable second best option saline can be used as a third choice but should be used for a limited duration of less than an",
        "Neck Injuries": "hour neck injuries the neck is a relatively unprotected area area of the body yet it contains critical structures such as the airway vascular structures and the cervical spine selective spinal immobilization criteria are now standard practice during cause involving neck injuries patients with neck injuries should always be considered difficult Airway patients due to the potential for compromised Airway Anatomy immediate attempts to achieve Hemorrhage control should be made in patients exhibiting sign signs of major vasculature Airway or digestive tract injuries if there is evidence of an air leak or expanding hematoma definitive Airway control should be attempted following these initial interventions the patient should be transported directly to the operating room for surgical exploration the neck is divided into three zones for classification Zone one is the most inferior defined by the clavical external Notch inferiorly and the horizontal plane dissecting the CID cartilage superiorly zone two is bordered by the CID cartilage inferiorly and the angle of the mandible superiorly lastly Zone 3 is bordered by the angle of the mandible inferiorly and the base of the skull superiorly in cases of neck trauma resulting in horseness and accompanied by skin LC ER ations ecosis tenderness subcutaneous enyma or Strider and immediate consult is needed the thyroid gland is highly vascular and direct trauma can lead to hematomas that may impinge on the airway in such cases surgical Airway management Ury may need to be located inferior to the usual site of thyroid insertion reports of thyrotoxicosis or thyroid storm following trauma have been documented and treatment is the same as for thyroid toxicosis from other causes lingot tracheal injuries while uncommon can occur in the cervical trachea area and are most often caused by direct blunt trauma such as strangulation closed line injuries or hanging penetrating lenot tracheal injuries account for approximately 10% of all penetrating neck injuries signs and symptoms may include bubbling from a neck wound subcutaneous air dysphonia dnia Strider visible wounds and swelling management includes careful indot tral intubation occlusive dressing for open neck wounds spinal precautions and transportation to appropriate Trauma Center vascular neck injuries can result in Rapid exanguination hematoma formation or the imization of air they account for approximately 1/4 of all penetrating injuries with high mortality rates early Airway securement direct pressure application with an occlusive dressing and maintaining the patient in the trendel bird position are components of Transport management M for vascular neck",
        "Abdominal Trauma": "injuries abdominal trauma recognizing abdominal trauma can be challenging as it may not always present with obvious external signs a comprehensive assessment can identify potential injuries and guiding appropriate care abdominal trauma can be categorized as either blunt or penetrating each with unique characteristics blunt trauma occurs when an external force is applied to the abdominal cavity such as in Falls or mvcs often these involve seat belts penetrating trauma on the other hand results from various objects like knives Firearms or other sharp objects and can be challenging to assess accurately due to the wide range of potential injuries the abdominal cavity is extensive and houses numerous vital organs making it susceptible to injury organs like the spleen liver kidneys aorta urinary bladder gallbladder small and large intestines pancreas and stomach have limited protection and are prone to damage both types of trauma can lead to life-threatening Hemorrhage and severe organ damage even when there is no visible external signs of injury therefore understanding the mechanism of injury is essential when assessing for abdominal trauma diagnosing abdominal trauma involves assessing the patient's history conducting a thorough physical examination and paying attention to any indications of internal bleeding the gray Turner sign and Cullen sign which are ecosis in the flanks and per umbilical region respectively may suggest internal bleeding during the assessment gather information about the events leading up to the injury and perform a physical exam to identify signs of blood loss this includes inspection oscilation and palpation of the abdomen however providers should perform the primary assessment at the bedside rather than during trans support in order to promply address any life-threatening issues signs and symptoms of abdominal trauma serve as indicators for assessing the severity and extent of internal injuries guiding timely and appropriate treatment interventions altered mental status in a patient with abdominal trauma can signify various issues including hypmic shock intracranial injury due to trauma or inadequate oxygenation and profusion to the brain evaluating the patient's mental status helps identify any neurological complications and determines their overall condition teoc cardia is a common response to abdominal trauma and occurs as the body attempts to compensate for blood loss or shock the rapid heart rate aims to maintain adequate profusion in vital organs but also signals the severity of the trauma and the need for intervention the absence of palpable pulses particularly in the extremities can result from reduced cardiac output due to blood loss or shock this finding suggests compromised circulation and mandates immediate attention to restore profusion a tense or rigid abdomen is often an ominous sign of intraabdominal pathology such as internal bleeding or organ injury the abdominal muscles contract involuntarily in response to irritation inflammation or injury within the abdominal cavity causing discomfort in guarding providers must recognize this symptom as it indicates the need for further assessment and intervention pale and moist skin may result from shock and Vaso constriction as a body redirects blood flow to essential organs power can help identify the presence of hypothalmic shock and provides valuable information for treatment decisions poor peripheral profusion characterized by weak or absent peripheral pulses and delayed capillary refill is a clear indicator of circulatory compromise hypotension is a serious and life-threatening sign in the context of abdominal trauma it signifies a severe loss of blood or shock and requires immediate resuscitation efforts to stabilize the patient's hemodynamic status these clinical indicators collectively provide valuable insights into the patient's condition and help guide the appropriate course of treatment for abdominal trauma prompt recognition and assessment of these signs and symptoms are essential for delivering timely and effective care ultimately improving the patient chances of a positive outcome the management of abdominal trauma is a critical aspect of prehospital care and involves a systematic approach to assessing and stabilizing the patient's condition before and during transport here are the key elements of abdominal trauma management during transport first administer appropriate oxygen therapy ensuring that the patient receives adequate oxygen is essential as hypoxia can exacerbate the effects of abdominal trauma oxygen therapy should be administered based on the patient's oxygen saturation and respiratory status establish large bore vascular access and consider placement of a central line adequate vascular access is essential for the administration of fluids blood products and medications large Bor peripheral IV lines are typically established and in cases where rapid and consistent access is needed consideration may be given to placing a central line to ensure adequate tissue profusion providers should maintain the patient's blood pressure within specific Target ranges typically a systolic blood pressure of 80 to 90 mm of mercury or a mean arterial pressure of 60 to 65 mm of mercury is targeted but these goals may vary depending on the patient's age and medical IAL history fluid resuscitation is an integral part of managing abdominal trauma a bolus of crystalloid fluid is administered in 250 to 500 mL increments titrated to the patient's blood pressure map or CVP this approach helps restore intravascular volume while monitoring for signs of overhydration patients with abdominal trauma may require Airway management indot tral intubation or other Airway interventions should be performed if there is evidence of Airway compromise in cases of significant Hemorrhage or shock the administration of blood products such as packed red blood cells fresh frozen plasma and platelets may be necessary to correct coagulopathies and restore blood volume in most cases it is advisable to insert an indwelling urinary catheter to monitor urine output and assess for possible gu injuries however if there is a suspicion of a urethal injury catheter placement should be avoided keep the patient warm as hypothermia can exacerbate the effects of shock and Trauma maintain the patient's body temperature through insulation and warm blankets during transport open abdominal wounds should be covered with sterile dressings to prevent contamination and infection additionally an occlusive dressing is applied over sterile dressings to prevent evaporative cooling and maintain a warm",
        "Resuscitative Endovascular Balloon Occlusion of the Aorta": "environment resuscitative endovascular Bloon occlusion of the aorta resuscitate ative endovascular balloon occlusion of the aorta or raboa is a temporizing measure used in specific critical situations to manage refractory hemorrhagic shock and control bleeding in traumatic and non-traumatic scenarios this procedure is particularly relevant for the critical care transport provider who may encounter patients requiring this intervention during inner facility transfers here is an expanded explanation of riboa its indications procedure zones and considerations indications for raboa raboa is considered when traditional methods of hemorrhage control such as direct pressure tourniquet and hemostatic agents have failed to stabilize the patient with severe bleeding in cases of severe abdominal trauma with uncontrollable bleeding roboa can temporarily control hemorrhage until definitive surgical intervention is possible pelvic fractures often result in substantial bleeding the device can be used to temporarily halt blood loss from these injuries reboa may be employed as a bridged surgery for patients with a ruptured abdominal aortic aneurysm helping to maintain hemodynamic stability until the repair is performed lastly it can be initiated at a peripheral facility to stabilize a patient with life-threatening Hemorrhage before transfer to a trauma center with Advanced surgical capabilities procedure a small balloon catheter is inserted through the femoral artery and advanced into the aorta the depth and of insertion depends on the specific goals of treatment and the location of the bleeding Source once the catheter is appropriately positioned the balloon is inflated this inflation includes the aorta achieving two critical effects first it prevents additional bleeding below the level of the balloon thereby controlling Hemorrhage and it increases cardiac afterload above the level of the balloon which improves coronary and cerebral profusion the raboa divides the aorta into three zones Zone one extends from the takeoff of the left sub caving artery to the Celiac trunk zone two spans from the Celiac trunk to the lowest renal artery and zone three encompasses the segment from the lowest renal artery to the bifurcation of the femoral arteries providers should closely monitor the arterial line tracing during reboa placement any changes in waveform or pressure range should be promptly reported to medical control or the receiving facility the catheter should not be repositioned or removed without fully deflating the balloon raboa poses significant risks and its use should be considered a bridge to definitive intervention in an anoc Cathy Suite or operating room the underlying source of hemorrhage must be addressed promptly once the patient is",
        "Hollow Versus Solid Organ Injury": "stabilized Hollow versus solid organ injury hollow organs such as the stomach intestines gallbladder urinary bladder uers uterus and the great vessels of the descending aorta and the inferior vena pose unique challenges when injured as they tend to leak their contents in cases of injury to these hollow organs the primary concern is the potential development of peritonitis an inflammation of the perenium lining in the abdominal cavity on the other hand solid organs like the liver spleen pancreas and kidneys typically bleed when injured treatment of injuries to solid organs should be oriented towards managing shock and ensuring an expeditious transport to an appropriate medical facility the spleen is a vital organ with unique characteristics in the abdominal cavity it receives its direct vascular Supply from the aorta and drains directly into the inferior venne Cava consequently it is the most commonly injured organ in the abdominal cavity with young adults and individuals with conditions like CLE cell disease or mononucleosis being at particular risk signs and symptoms of a spleen injury often include pain in the area of the spleen along with a specific sign known as Cur sign which manifests as referred pain in the shoulder due to irritation of the diaphragm in cases of spleen injury transport management involves providing oxygen and monitoring the patients ABCs along with appropriate treatment for signs and symptoms of hypmic shock the liver the largest organ in the abdominal cavity and highly vascular is another organ of concern in abdominal trauma injured liver typically presents with pain in the right upper quadrant and similar to spleen injury may cause Cur sign resulting in pain radiating to the right shoulder as blood accumulates around the diaphragm unlike the past where surgery was the First Option current management of liver injuries often involves observation as the liver has a remarkable ability to heal over time additionally angioembolization an Interventional Radiology technique has become increasingly popular as a method for controlling Hemorrhage from the liver the stomach while rarely damaged by trauma can be affected in specific circumstances the most common causes of stomach injury are when the stomach is full and gets compressed against the steering wheel during motor vehicle collisions or when there's a penetrating injury due to the Rarity of stomach injuries specific signs and symptoms may not always be evident but abdominal trauma assessments should always consider the possibility of stomach involvement in appropriate clinical contexts the large and small intestines assists in digestion and nutrient absorption making them vital organs in the abdominal cavity when it comes to trauma penetrating injuries are the most common type of injury affecting these organs penetrating trauma such as gunshot wounds is the primary cause of injury to the large intestine accounting for a significant percentage of cases rough 96% in contrast the small bow can be injured by both penetrating and blunt trauma with the latter often occurring due to seat belt injuries in motor vehicle collisions signs and symptoms of intestinal injuries can vary but may include an eotic area across the lower portion of the abdomen commonly referred to as the seat belt sign other clinical indicators of intestinal injury Inc Compass the presence of pain with palpation of the abdomen as well as guarding abdominal distension rebound tenderness and vomiting due to the potential for Ault injury maintaining a high index of Suspicion for intestinal injury is essential during the assessment of abdominal trauma patients additionally establishing large bore IV access and considering the presence of conc om minent injuries such as chest neck or lumbar spine injuries is essential in the transport management of these cases in contrast the dadum which is a retrop peronal organ is relatively well protected within the abdominal cavity it may not necessarily produce noticeable symptoms when ruptured making the diagnosis of dadal inju is particularly challenging hence Healthcare Providers should maintain maintain vigilance and consider the possibility of dual injury in cases of abdominal trauma especially when the mechanism of injury suggests potential involvement of this organ vascular injuries involving major blood vessels in the abdomen are typically life-threatening due to the potential for severe Hemorrhage and hemodynamic instability these vessels include the aorta inferior Vena left or right renal artery Superior or inferior mesenteric artery and left or right iliac artery given the critical role these vessels play in blood circulation entries to them can have dire consequences signs and symptoms of vascular injuries in the abdomen can vary widely and may even be initially absent patients might present with altered mental status reflecting inadequate cerebral profusion or they may rapidly progress into hypoy shock due to the potential for Rapid deterioration the management of these injuries is time sensitive in the prehospital setting providers should prioritize maintaining Airway patency and ensuring adequate ventilation to optimize oxygen delivery to tissues judicious fluid resuscitation is essential to maintain tissue profusion while avoiding volume overload however the primary focus should be on expedit transportation to a trauma center with the capability to manage vascular injuries",
        "Pelvic Trauma": "promptly pelvic trauma pelvic fractures typically result from high impact events such as motor vehicle collisions pedestrian versus motor vehicle collisions motorcycle crashes and Falls these incidents generate significant forces that can cause severe injuries providers assessing patients with ppic fractures should remain vigilant for additional injuries as such traumas often occur in conjunction with other bodily harm these fractures can be life-threatening due to the rich blood supply to the pelvis from the left and right iliac arteries additionally the veins within the pelvis are thin and valveless making them susceptible to tearing and causing internal hemorrhage this internal bleeding can rapidly lead to hypothalmic shock the pelvis also houses critical structures such as the female reproductive organs and the bladder which can rupture in both sexes during pelvic fractures signs and symptoms include the rotation or uneven height of the iliac crests uneven length of the legs tenderness upon palpation of the posterior aspect of the pelvic ring and the presence of pain crepitus or movement on gentle lateral compression and inward compression in terms of management it's essential to splint the fracture to restrict movement and stabilize the pelvis as movement can exacerbate bleeding patients with pelvic fractures should also be treated for signs and symptoms of shock if there is any soft tissue damage to the genitalia it should be appropriately managed the patient can be packaged for transport using motion restriction measures on a scoop stretcher or similar transfer device alternatively a pelvic binder may be employed to help stabilize the fracture an open book fracture which results from anterior posterior compressive forces separating the pelvis at the symphysis pub can lead to significant bleeding reducing these fractures can help control bleeding and should be achieved using methods like pelvic binders or pneumatic anti-shock garments signs symptoms and management for openbook fractures are similar to those for pelvic fractures and prompt medical attention is critical in both",
        "Extremity Trauma": "cases extremity trauma muscular skeletal injuries while rarely life-threatening in themselves Encompass a range of conditions such as fractures sprains strains dislocations muscular contusions compartment syndromes and Crush syndromes these injuries can provide valuable insights into the amount of energy transferred into the body during trauma helping Healthcare Providers assess the likelihood of addition injuries that may not be immediately apparent properly splinting muscular skeletal injuries prevents further damage and promotes the healing process additionally patients with these injuries often experience significant pain necessitating the administration of appropriate pain medications to alleviate their discomfort healthc care providers should conduct a thorough assessment of the six PS pain power pulselessness paresthesia paralysis and pressure both before and after any manipulation of the injured area this assessment helps in monitoring the patient's condition ensuring that blood flow and nerve function are not compromised and that the injury is not worsening due to interventions or immobilization fractures are common muscular skeletal injuries that can be categorized into open and closed closed closed fractures occur when the skin remains intact reducing the risk of infection however they may still involve internal bleeding particularly in the case of long bones like the femur open fractures on the other hand are characterized by a break in the skin overlying the fractured bone which poses a higher risk of infection these types of fractures are typically the result of high energy injuries and may lead to significant blood loss signs and symptoms include pain swelling deformity rigidity shortening of the affected limb ecosis guarding and crepitus management of isolated fractures involves several steps starting with the maintenance of an open Airway and the provision of appropriate oxygen therapy providers should assess pulses motor function and sensory function distal to the fracture site to ensure adequate circulation control of bleeding is essential and can be achieved with direct pressure and pressure dressings if bleeding is not adequately controlled the application of a tourniquet may be necessary any exposed bone or tissue should be covered with aeral dressing IV fluids should be initiated and analgesic medications may be administered to manage pain to stabilize the fracture the extremity should be splinted in its normal anatomic position after splint application or manipulation the provider should reassess pulses and motor and sensory function distal to the fracture site continuous monitoring of oxygen saturation Vital Signs and cardiac activity ensures the patient's overall condition is maintained during fracture management when dealing with extremity fractures it's important to consider different treatment modalities casting a common approach for certain fractures is usually performed at least 24 hours after the injury to allow for swelling reduction however providers must be aware that swelling under a cast can lead to compartment syndrome a condition characterized by increased pressure within a muscle compartment that can compromise circulation in nerve function when transporting a patient with a cast evaluating neurovascular function distal to the cast is important both before and periodically during transport to monitor for signs of compartment syndrome for fractures that require realignment or reduction this is a priority only when neurovascular function distal to the injury is compromised gentle Traction in the anatomical direction of the bone distal to the fracture while stabilizing the bone bone proximal to the brake is applied to bring the bone into alignment or a position that maximizes the pulse sensation the bone is INS splinted in that direction to maintain alignment external fixation is another method used for certain fractures and during transport providers should ensure adequate padding and comfortable positioning to prevent pressure sores or discomfort of the patient internal fixation a surgical approach to stabiliz fractures using devices like plates and screws is generally not a concern during transport and is typically performed in a controlled hospital setting compartment syndrome is a condition that arises when bleeding or swelling occurs within a non-stretchable fascia that divides an extremity into compartments this increased pressure within the compartment compresses the arteries and veins impeding adequate profusion of the muscles and leading to a Cascade of symptoms while compartment syndrome can develop in various anatomical locations it is most commonly seen in the forearms and lower legs although it can also occur in other extremities and even the buttocks the condition may be triggered by a range of factors including Burns external compression or crushing injuries and it usually progress resses over hours signs and symptoms are distinctive and include pain poar pulselessness paresthesia paralysis increased pressure within the compartment and po kilmia which refers to affected extremities that may feel colder compared to unaffected areas these signs are indicative of the compromised blood supply and nerve function within the affected compartment when managing compartment syndrome during transport certain measures should be taken to alleviate the condition maintaining an open Airway and providing oxygen therapy as necessary is critical to address any Associated respiratory distress the assessment of pulses and evaluation of motor ins sensory function in the affected extremity are essential to monitor the progression of compartment syndrome elevating the extremity above the level of the heart can help reduce swelling and the application of ice packs over the affected area May provide some relief initiating IV fluids is important to maintain peripheral profusion and pain medication should be administered to alleviate the patient's discomfort loosening constrictive splint material and clothing over the effected area can also help alleviate pressure additionally providers should closely monitor the patient for signs of complications such as rabdom mysis hyperemia and myoglobinuria prompt recognition in management of compartment syndrome can prevent further tissue damage and complications rabdom myolysis is a condition characterized by damage to the sacma the muscle cell membrane which can occur due to various underlying causes this damage allows the influx of calcium and sodium ions into the muscle cells followed by an influx of water leading to the rupture of muscle fibers and the release of substances that initiate a chain of events the leading causes of rabdom mysis include strenuous exercise alcohol abuse drug abuse infections trauma and even seizures Crush syndrome is a severe form of rabom mysis and is sometimes referred to as the smiling death phenomenon in crush syndrome patients may appear happy and smiling when initially extricated but this is often followed by sudden Cardiac Arrest when released potassium levels reach the heart signs and symptoms of rabdom mysis can vary but typically include motor weakness evidence of trauma or compression sensory loss dehydration dark or brown urine and microscopic analysis of urine showing blood with only a few red blood cells laboratory findings often reveal significant elevations in creatine canas levels which are about five times normal or higher hyperemia with Associated ECG changes and hypocalcemia with prolonged QT intervals on the ECG in the transport management of rabdom mysis several critical steps are taken to address the condition and its potential complications administering a significant volume of saline usually 2 liters or more helps flush out the toxic substances release from the damage muscles sodium bicarbonate may also be administered at a dose of 1 mil equivalent per kilogram to alaniz the urine and prevent kidney damage continuous monitoring of the patient's cardiac status through a heart monitor is essential especially due to the risk of hyperkalemia if signs of elevated potassium do develop calcium may be administered as a slow intravenous push with frequent monitoring for severe bardia inserting an indwelling urinary catheter and maintaining a urine out put of 300 MLS per hour helps in Flushing out myoglobulin and preventing kidney injury bicarbonate may be given to maintain urine pH at or above 7.65 and manitol may be administered if the patient is producing urine during in facility transfers ongoing monitoring of electrolytes is essential to ensure appropriate Management in cases of a pulseless extremity due to severe rabdom mysis repositioning should be approached with caution and manual traction should be used to align the long bone anatomically for dislocations analgesia and benzodiazapines may be used to relax muscles and facilitate",
        "Trauma to Special Populations": "repositioning trauma to special populations geriatric trauma presents unique challenges in the field of emergency medicine necessitating Specialized Care due to the physiological changes and increased prevalence of comorbid conditions in this population as of 2013 there were approximately 44.7 million Americans age 65 or older constituting 14.1% of the population and this number is projected to increase significantly to 98 Million by 2060 mortality rates begin to rise after the age of 30 and the incidence of complicating comorbid conditions such as diabetes hypertension and cardiovascular disease also escalates with age when assessing geriatric trauma patients several key considerations come into play first the presence of Dentures or other Dental devices can impact Airway management and may necessitate extra attention to Airway clearance Additionally the common age related condition known as kyphosis results in forward curvature of the spine and may affect the patient's posture and Airway alignment these patients often exhibit A reduced cough reflex making them more susceptible to aspiration which may require additional suctioning interventions furthermore the nasal tissues of elderly individuals tend to be fragile and prone to injury psychological changes in the respiratory system are also observed in geriatric patients including a reduced vital capacity and decreased chest Excursion this leads to reduced tial volume and lower minute ventilation which can affect their ability to adequately oxygenate and ventilate during assessments for shock and profusion clinicians should be aware of potential capillary refill delays which can be exacerbated by medications pacemakers and pre-existing hypertension it's important to note that slow responses to questions should not be immediately attributed to head trauma as cognitive function can and sometimes does decline with age in terms of management considerations providers must maintain temperature control due to this patient decreased ability to Thermo regulate when using splits or backboards for mobilization extra padding is often required as geriatric patients tend to have reduced subcutaneous fat making them more susceptible to pressure sores and discomfort trauma during pregnancy is a complex and challenging situation that requires Specialized Care and consideration due to the unique physiologic changes that occur in pregnant patients these changes complicate the management of trauma and necessitate careful attention to the well-being of both the mother and the developing fetus abdominal injuries in pregnant patients present a unique set of challenges the physiological changes in pregnancy such as increased blood volume and cardiac output can mimic the signs of shock making it difficult for healthcare providers to recognize the subtle differences additionally the risk of massive blood loss is considerably higher when trauma involves the Bony pelvis due to the increased blood flow to the uterus during pregnancy any pregnant patient with a pelvic injury should be regarded with a high index of Suspicion as they may ex anguin rapidly bladder and urine injuries are common in these cases further emphasizing the importance of vigilance and immediate intervention abruptio placente is a severe complication that can occur in pregnant patients as a result of trauma it is responsible for approximately 70% of fetal demise in cases of blunt trauma during pregnancy signs and symptoms include vaginal bleeding abdominal and back pain uterine tenderness signs of shock and a lack of fetal heart sounds the management of a pregnant patient with a brop placente involves several clinical steps the patient is beyond 20 weeks of gestation it is essential to tilt her left laterally by at least 15\u00b0 to prevent vnea syndrome which can compromise blood flow to the heart bleeding control is a priority and early IV access should be established for judicious fluid resuscitation maintaining the patient's Airway and providing appropriate oxygen therapy or vital as the rapid transportation a of the patient to a facility equipped to manage both maternal and Fetal",
        "Flight Considerations": "needs flight considerations there are several reasons why Air transport is favored in severe trauma cases firstly it offers a significant reduction in travel time especially when compared to ground transportation in remote or roll areas where Trauma Centers may be located far away helicopters and aircraft can cover vast distances quickly ensuring that patients reach the appropriate facility in a timely manner this rapid response is vital for trauma patients as it can make the difference between life and death secondly Air transport allows for more direct and efficient access to specialized Trauma Centers these centers are equipped with highly trained Medical Teams and advanced resources that are specifically geared towards managing severe trauma cases Air transport can bypass traffic congestion challenging terrain or other obstacles that ground ambulances May encounter ensuring that patients receive the necessary care as quickly as possible moreover Air transport is particularly valuable when considering the golden hour principle in trauma care this principle emphasizes the critical importance of delivering definitive care within the first hour following a traumatic injury Air transport significantly increases the likelihood of meeting this time sensitive goal as it eliminates delays associated with navigating through urban areas or challenging Landscapes additionally for patients with severe trauma the speed and efficiency of Air transport minimizes the potential complications and deterioration that may occur during prolonged ground transport it allows for early interventions such as Airway management Hemorrhage control and administration of intravenous fluids and medications which can be initiated by skilled flight Medical  Teams a"
    },
    {
        "Introduction": "Burns introduction according to the American burn Association there is a significant burden of burn injuries in the United States with an estimated 1 million cases occurring annually in the year 2020 there were a total of 132 specialized burn centers across the country each admitting an average of 200 burn cases per year these burn injuries which necessitate admission typically involve a substantial portion of the total body surface area with an average size of 14% unfortunately approximately 4% of patients admitted to burn Centers do not survive their injuries highlighting the severity of these cases the highest incidence of burn injuries is observed in two distinct age groups the first few years of life emphasizing pediatric vulnerability and individuals between 20 and 29 years of age furthermore it is noteworthy that males account for a majority of burn cases constituting 71% of the total and the primary causitive agent is flame related incidents most admissions to burn centers require immediate Transportation via EMS to ensure access access to Specialized Care the critical nature of burns is underscored by the fact that the initial 24 hours of care are Central in determining patient outcomes therefore Critical Care transport providers play a pivotal role in ensuring the safe and effective transfer of burn patients as complications can arise during Transit the central focus of this chapter on Burn care encompasses a comprehensive understanding of the anatomy and function of the skin the physiology of burn injuries classification of burn severity thorough assessment techniques effective management strategies and addressing special situations that may arise in the context of burn injuries this multifaceted approach is essential in providing the best possible care for burn patients and improving their chances of recovery",
        "Anatomy and Function of the Skin": "anatomy and function of the skin the skin the body's largest organ is a vital barrier that helps the body maintain homeostasis composed of two principal layers the epidermis and dermis it forms a complex structure with distinct functions the epidermis the outermost layer is responsible for the Skin's water prooving and defense against external pathogens within the epidermis several levels including the stratum corneum stratum granulosum stratum spinosum and stratum basil collaborate to carry out functions such as keratin production immune response and cell turnover beneath the epidermis lies the dermis which consists of the papillary and reticular layers the dermis provides structural support and is home to various essential components including blood vessels nerves hair follicles and sweat glands the papillary layer is responsible for nutrient supply to the epidermis while the reticular layer offers strength and elasticity to the Skin Within These layers specialized cells such as fiber blasts and melanocytes contribute to collagen production pigmentation and wound healing the epidermis is the outermost layer of the skin and protects the body from the external environmental factors and pathogens that attack it on a daily basis in thin skin regions such as most of the body's surface the epidermis is composed of four layers namely the stratum basil stratum spinosum stratum granulosum and stratum corneum these layers work collectively to provide a barrier against water loss and infection however on the palms of the hands fingertips and the soles of the feet which would be considered thick skin areas an additional layer called the stratum lucidum is present between the stratum granulosum and the stratum corneum this stratum contributes to the unique thickness and durability of the skin in these regions the stratum basil is the deepest layer firmly attached to the dermis and responsible for continual cell division ensuring the Regeneration of the epidermis above it the stratum spinosum often referred to as the prickly layer contains keratin aites that produce keratin a structural protein that is vital for skin strength and resilience kocy maturation and lipid synthesis which contributes to the Skin's water resistant properties occurs in the stratum granulosum in thick skin the stratum lucidum adds an extra layer of protection while the outermost stratum corneum consists of dead flattened keratinocytes forming a tough impermeable layer the stratum Corum is the outermost layer of the epidermis and serves as a critical component of the Skin's protective barrier its primary functions include preventing water loss from the underlying tissues protecting against environmental stressors and acting as the first line of defense against injury and infection one of the key features of the stratum cordum is this continuous renewal process skin cells originate in the deeper layers of the epidermis and gradually migrate towards the surface as they undergo a process of differentiation and keratinization this takes approximately 2 to 3 weeks for skin cells to transform into a fully matured keratin aite from the stratum corneum once at the surface these keratinocytes are no longer viable and are sloughed off in a natural shedding process the shedding of dead cells helps maintain the Skin's integrity and ensures that newer healthier cells replace the old ones additionally this continuous renewal process AIDS in the the removal of potential pathogens and contaminants that may have adhered to the skin surface the dermis is the second layer of the skin positioned beneath the epidermis and its role is to maintain the Skin's structural integrity and functionality comprising a complex network of connective tissue cell types and various specialized structures the dermis is vital for overall skin Health cellular components of the dermis include fibroblasts which are responsible for producing collagen in elastin macras that function in immune defense and debris clearance white blood cells for immune responses and mass cells involved in allergic reactions within the dermis a network of blood vest vessels lymphatic vessels nerve fibers hair follicles and oil and sweat glands can be found the papillary layer a sublayer of the dermis serves to Anchor the epidermis above it and is richly supplied with blood vessels which facilitate the exchange of nutrients and waste products between the epidermis and dermis the reticular layer comprising Approximately 80% of the dermis is characterized by dense connective tissue this connective tissue is responsible for making the skin durable and anchors various skined appendages such as hair follicles and sweat glands collagen fibers in the reticular layer are interlocked and run in different planes usually parallel to the skin surface these fibers known as lines of cleavage are important in surgical procedures and wound healing as they determine the direction in which the skin should be closed to minimize scarring the subcutaneous layer also known as The hypodermis Lies Beneath the dermis and contains subcutaneous fat connective tissue sweat glands muscle tissue and sometimes even bone the hypodermis serves as a cushion insulator and energy storage site while also Al providing stability to the skin the process of healing is a complex and highly regulated sequence of events in the body's response to tissue injury it involves various specialized cells and molecules each playing a distinct role in restoring damaged tissues fibroblasts are responsible for synthesizing essential proteins such as collagen and fibronectin collagen provides structural support and helps in wound closure while fiber nectin AIDS in cell migration and tissue repair collectively contributing to the restoration of the skin macras which are normally present in tissues become more abundant at the site of injury these immune cells play a role in the healing process by releasing chemical Messengers that attract other cells involved in wound healing they act as orchestrators of the immune response and tissue repair ensuring that the right cells are recruited to the injured area at the right time endothelial cells also play a significant role in healing by facilitating the Regeneration of blood vessels they build new capillaries a process known as angiogenesis to restore blood flow to the injured tissue this reestablishment of blood blood supply is critical for providing nutrients and oxygen to the healing site aiding in the repair process and helping to prevent infection the process of healing in the context of skin injuries is closely tied to the Skin's multifaceted functions Each of which plays a vital role in maintaining overall health firstly the skin serves as a primary protective barrier shielding the body from harmful pathogens physical trauma and environmental hazards secondly it has an essential immunologic function as it houses immune cells that can detect and respond to potential threats Additionally the skin is essential for Thermo regulation helping the body maintain a stable internal temperature through mechanisms such as sweating invasive constriction the skin also helps in maintaining aing fluid and electrolyte balance preventing excessive fluid loss and essential ions metabolically the skin contributes to the synthesis of vitamin D when exposed to sunlight a process that is necessary for calcium homeostasis neurosensory functions allow the skin to detect various stimuli including pain temperature and touch facilitating our interaction with the external environment lastly the skin has social significance contributing to our appearance and interpersonal interactions when the skin is compromised due to injuries such as burns the degree of dysfunction is determined by the extent and the depth of the burn more severe burns can disrupt multiple functions simultaneously leading to a range of medical complications understanding the intricate roles of the skin that the impact of burns on these functions is important for healthcare professionals so that they may provide effective treatment and support during the healing process as well as to minimize long-term complications and optimize the restoration of skin",
        "Physiology of Burns": "function physiology of burns the physiology of burns comprise a wide range of causes each with its own unique mechanisms and effects on the body these causes include Flame or Flash Burns these Burns occur when exposure to flames or sudden bursts of intense Heat result in tissue damage the extreme temperature of flames can cause rapid skin injury and deeper tissue damage scald Burns these are caused by hot liquids such as water or Grease coming in contact with the skin the severity will depend on the temperature and duration of exposure contact Burns result from direct contact with hot objects or surfaces leading to localized tissue damage these Burns can vary in severity based on the object's temperature and duration of contact electrical Burns occur when electrical current passes through the body causing tissue damage along the path of the current these Burns can be particularly complex and may involve both external and internal injuries chemical burns result from exposure to corrosive chemicals that damage the skin and underlying tissues the severity depends on the type and concentration of the chemical involved radiation Burns can occur due to exposure of ionizing radiation such as x-rays or nuclear these Burns damage tissues at the the cellular level and can have severe consequences lastly we have Burns caused by diseases certain diseases such as Stevens Johnson syndrome and toxic epidural necrolysis can lead to burn-like injuries on the skin these conditions are characterized by severe skin reactions and can be lifethreatening thermal Burns a subset of burns are cause back exposure to extreme temperatures even relatively moderate temperatures such as 113\u00b0 F can cause cell damage and denaturation of cellular proteins a temperature of 120\u00b0 fhe can result in a full thickness burn in as little as 5 minutes while a temperature of 159\u00b0 fhe can cause a full thickness burn in just one second regardless of the cause or severity all Burns result in varying degrees of tissue damage and functional impairment in terms of the anatomy of a burn there are three distinct zones Zone one is known as a zone of coagulation this is the innermost Zone and represents the area of the burn where the skin comes into direct contact with the heat Source or the most extreme temperature in this Zone tissue damage is the most severe leading to irreversible coagulative necrosis coagulation necrosis occurs when the high temperature causes proteins and cell structures to denature and lose their functionality this zone is the primary focus of surgical intervention as it typically requires excision and grafting to restore tissue function zone two is the zone of stasis surrounding the zone of coagulation is the zone of stasis in this area tissue damage is less severe than in the coagulation Zone but blood flow is significantly compromised which can lead to es schic tissues stagnant blood flow and inflammation can further exacerbate tissue damage potentially resulting in tissue death if not adequately managed prompt and appropriate care is essential in this Zone to prevent the progression of tissue damage and Salvage viable tissue the outermost zone is the zone of arithma where there is increased blood flow and minimal tissue damage this Zone typically exhibits redness and inflammation due to the body's natural response to injury fortunately tissues in this zone are more likely to recover with proper wound care and management monitoring this Zone can provide insights into the overall progress nosis of the burn injury understanding the anatomy of a burn and the differentiation of these zones is critical for healthc Care Professionals in determining the appropriate treatment strategies for burn patients the goal is to minimize tissue damage prevent complications and promote the healing and functional restoration of the affected area taking into account the unique characteristics of each Zone within the burn injury the systemic inflammatory response in a burn patient is a complex physiological reaction that can have significant implications on overall health inflammation to a certain extent is a normal and necessary response to an injury including Burns that helps the body initiate the healing process by recruiting immune cells enhancing blood flow and removing moving damaged tissue however in the context of extensive burns the inflammatory response can become excessive and lead to various problems affecting other tissues and organs burn injuries involving more than 20% of the total body surface area often trigger a systemic inflammatory response this heightened response can result in several problems excessive inflammation can cause proteins to leak into subcutaneous tissues at uninjured sites leading to edema and swelling moreover it may reduce the pressure at which proteins and fluids are retained within blood vessels increasing the risk of pulmonary edema which can impair oxygen Exchange in the lungs and lead to respiratory distress the systemic inflammatory response can suppress the immune system's normal functioning making making the patient more susceptible to infections this immune suppression can delay the body's ability to fight off pathogens and hinder the healing process burn related inflammation can also result in the dysfunction of endothelial cells in the intestine leading to an increased permeability allowing bacteria and toxins from the gut to enter into the bloodstream potentially leading to sepsis and other systemic infections lastly the systemic inflammatory response can also affect the cardiovascular system leading to reduce cardiac output this in turn causes inadequate tissue profusion and oxygen delivery to vital organs further complicating the patient's",
        "Classification of Burn Injuries": "condition classification of burn injuries the severity of a burn injury requires assessment that takes into account various factors including the extent depth and location of the burn as well as several patient specific considerations first and foremost the extent of the burn measured as a percentage of the total body surface area is a critical determinant of severity deeper Burns such as full thickness burns are more severe than superficial Burns Additionally the location of the burn can significantly impact its severity as burns on critical areas such as the face hands and feet may have more pronounced functional and cosmetic consequences Pediatric and elderly patients are generally more vulnerable to the effects of burns due to differences in skin thickness immune function and overall resilience furthermore theologic agents responsible for the burn whether they involve scalding liquids Flames chemicals or electrical sources can influence the degree of tissue damage and Associated complications inhalation injury is another critical consideration inhalation of hot gases or toxic fumes can damage the respiratory tract and lead to respiratory distress which significantly increases the severity of the burn injury lastly coexisting injuries are pre-existing medical conditions in the patient can complicate the assessment of burn severity these factors may affect the patient's overall physiologic reserve and ability to withstand the stress of a burn injury burn injuries are categorized into two main classifications based on the depth and severity of the tissue damage they cause the first classification system which we are probably most familiar with uses degrees categorizing burns into four main degrees first degree burns are superficial Burns that affect only the epidermis second three Burns involve damage to both the epidermis and the underlying dermis third degree burns destroy the entire epidermis and dermis often reaching the subcutaneous tissue beneath lastly we have fourth degree burns that are the most severe extending through the skin subcutaneous tissue and affecting underlying structures like muscles tendons and Bone the second classification system distinguishes between partial and full thickness Burns partial thickness Burns Encompass first and second degree burns that involve only damage to a portion of the skin layers while full thickness Burns correspond to a third or fourth degree burn meaning they affect all layers of the skin and probably deeper tissues superficial or first-degree burns are the mildest type of burn injury and primarily involve the epidermis these burns are commonly caused by exposure to UV light such as sunburn or from minor scald injuries and brief contact with hot services are even flash burs in first degree burns the skin appears red but typically do not develop blisters fortunately these burns are generally not associated with significant tissue damage and they often heal without scarring within approximately 7 Days prompt treatment including cooling the affected area and applying soothing creams can alleviate symptoms and facilitate the healing process for first degree burns as stated partial thickness or second degree burns are characterized by damage to both the epidermis and varying depths of the dermis there are two subcategories of partial thickness Burns superficial partial thickness Burns typically involve the epidermis and only a portion of the dermis sparing the deeper layers they are commonly caused by contact with hot liquids or brief exposure to Flame names these burns are characterized by the presence of blisters redness and intense pain upon palpation superficial partial thickness Burns typically heal within 14 to 21 days and while some scarring may occur it's often minimal and with proper wound care the skin generally regenerates without significant long-term issues how however deep partial thickness Burns extend deeper into the dermis and are often the result of exposure to steam hot oil or Flames distinguishing these from full thickness Burns can be challenging as both may present with blistering and skin damage the skin in deep partial thickness burns are blistered but not charred healing from these Burns is a more prolonged process often taking 21 days days or more and may require skin graphs or surgical interventions to achieve optimal closure scarring with deep partial thickness Burns is typically moderate and the patient may benefit from scar management strategies to minimize long-term cosmetic issues full thickness or third degree burns result in the complete destruction of both epidermal and dermal structures including nerve endings blood vessels and sweat glands as a result the skin appears pale dry and leathery often with a charred or white appearance one distinguishing feature of these Burns is the absence of pain in the affected area as the nerve endings responsible for transmitting pain signals have been destroyed however the surrounding areas with partial thickness Burns or uninjured skin may be painful and patients often experience significant discomfort during the healing process treatment typically involv surgical intervention as the damaged tissue cannot regenerate on its own skin graphs are necessary to replace the Lost tissue and facilitate wound closure during a skin graph procedure healthy skin is harvested from another part of the body known as an autograph or it could be obtained from a donor Source known as an olra and transplanted onto the burned area this grafting process helps in improving the function and appearance of the injured site despite medical intervention full thickness Burns often result in significant scarring which can be challenging to manage scar management strategies including Physical Therapy pressure garments and scar Vision surgery may be required to address the long-term cosmetic and functional issues associated with these severe burns subdermal or fourth degree burns represent the most severe of deep burn injuries extending beyond the skin and affecting deep structures these burns are often life-threatening and constitute a medical emergency in subdermal Burns the the skin and underlying tissues are extensively damaged resulting in the destruction of not only epidermal and dermal layers but also the underlying muscle and bone the affected area typically appears charred and the injury May extend down to vital structures nerve endings are completely destroyed rendering the injured area devoid of sensation due to the complexity and depth of subdermal burns Sur intervention is almost always necessary the primary goal of surgical management is to excise the necrotic tissue promote wound healing and minimize the risk of infection this process often involves multiple surgical procedures including extensive debent to remove damaged tissue and possibly the use of skin graphs or even more Advanced Techniques like tissue flaps in addition to the immediate surgical requirements patients with subdermal Burns may need ongoing Medical Care physical therapy and Rehabilitation to address the functional and cosmetic consequences of these severe injuries the extent of the damage and the potential for complications make these Burns a critical concern in Burn care necessitating a multidisiplinary approach involving burn Specialists surgeons and other Healthcare professionals to provide the best possible treatment and support to the patient burn size assessment is a fundamental aspect of evaluating the severity of burn injuries and determining the appropriate treatment course two common methods for estimating burn size are the rule of Nines in the Lund router chart the rule of nines is widely used for estimating the extent of burn injuries in adults it is based on the principle that the human body can be divided into specific areas each representing approximately % of the total body surface area this division includes areas such as the head each Upper Limb the anterior trunk the posterior trunk and then each lower limb the genitals account for approximately 1% using this method healthc Care Professionals can quickly estimate the total percentage affected by Burns which guides decisions regarding fluid resuscitation wound care and overall management the lond Browder chart is considered a more accurate method for estimating burn size especially in pediatric patients and individuals with irregular body shapes and is something that you'll more likely come in contact with as a critical care transport provider this chart provides a more detailed representation of the body taking into account the variations in body surface area for different age groups it divides the body into smaller regions allowing for a more precise assessment of burn size this method is particular valuable in determining the extent of Burns in children where the proportions of body parts change as they grow while this method is considered the preferred method for assessing burn size it is less practical for use in 911 settings this is because it requires a reference chart and may be challenging to memorize in such situations the rule of NES remains a more commonly used method due to its Simplicity and ease application however healthc Care Professionals May transition to the Lun Browder chart for more accurate assessments particularly when planning long-term burn care determining prognosis or evaluating the need for specialized interventions like surgery or skin grass major Burns typically involve a significant percentage of the total body surface area or TB sa in adults this is defined as Burns covering 25% or more of the tbsa for children under 10 and adults over 40 major Burns are those affecting 20% or more of the total body surface area the larger the burn area the greater the potential for complications such as fluid loss infection and systemic inflammatory responses full thickness Burns where all layers of the skin are damaged are considered major if they affect more than 10% of the tbsa these burns are often challenging to manage and require Specialized Care major Burns include those affecting critical areas such as the face Eyes Ears hands feet or perenium Burns in these regions can have significant functional and cosmetic implications and are going to require specialized treatment Burns caused by high voltage electrical injuries are considered major due to the potential for deep tissue damage including muscles and nerves these injuries can lead to systemic complications and may necessitate amputations or extensive surgical procedures Burns associated with inhalation injury or toxic fumes or heat damage the respiratory tract are characterized as major Burns additionally Burns that occur in conjunction with major trauma such as fractures or internal injuries are considered major due to the complexity of care required Burns sustained by patients who were already high risk or debilitated due to underlying medical conditions are classified as major these patients may have compromised immune systems impaired wound healing or other health concerns that increase the complexity of burn management moderate burn injuries are characterized by a moderate degree of tbsa involvement and a lesser extent of full thickness injury this category encompasses several criteria in adults moderate Burns involve 15 to 25% of the tbss with less than 10% of the affected area being full thickness Burns this means that the majority of the burn injury is partial thickness in nature affecting the epidermis and varying depths of the dermis moderate Burns in adults may still be significant but are less extensive compared to major Burns for children under 10 years of age and adults over 40 moderate burn Burns Encompass 10 to 20% of the tbsa with less than 10% of the affected area being a full thickness burn these age specific criteria acknowledge that younger and older individuals may have different physiological responses to burn injuries necessitating adjusted thresholds for categorization in any patient younger than 50 years Burns involving 10% or less of the tbsa are considered moderate if they do not present a threat to functional or cosmetic impairment of critical areas this recognizes that even relatively small Burns in these anatomically sensitive areas can have significant consequences for function and appearance moderate Burns while less extensive than major Burns still require prompt and appropriate medical attention depending on the specifics of the burn injury treatment may involve wound care pain management and monitoring for potential complications such as infections or scarring minor burn injuries are characterized by their limited extent and less severe nature compared to major or moderate Burns these Burns fall into two specific criteria in adults major Burns Encompass partial thickness Burns involving less than 15% of the tbsa for children under 20 and adults over 50 the threshold is even lower with minor burns defined as those affecting less than 10% of the tbsa these criteria consider age related differences in tissue healing and response to burn injuries partial thickness Burns involve damage to the epidermis varying depths of the dermis but do not extend through all skin layers minor burns can also include full thickness Burns covering 2% or less of the tbsa provided they do not pose a significant functional or cosmetic risk to critical areas full thickness Burns involve the destruction of all layers of skin and typically require specialized interventions minor burn injuries while less extensive still require appropriate medical attention to ensure proper wound healing pain management and the prevention of",
        "Assessment": "complications assessment Healthcare Providers should conduct a thorough initial assessment when evaluating a burn patient this assessment includes obtaining a focused history to gather information about the mechanis ISM of injury the duration and nature of the burn any pre-existing medical conditions allergies medications and the patient's immunization status a comprehensive physical examination should follow which involves assessing the burn size depth and location as well as evaluating the patient's Vital Signs and overall condition this information is critical for determining the severity of the burn guiding initial intervention and developing a treatment plan in cases where a burn patient may have experienced trauma in addition to the burn injury providers should exercise caution especially if there is suspicion of cervical spine injury spinal precautions and immobilization should be maintained until the spine can be cleared through appropriate Imaging studies this is to prevent further injury to the spinal cord as burn patients may be at a higher risk for con ominent traumatic injuries due to accidents or events leading to the burn when assessing a burn patient providers should refrain from solely relying on histories and examinations conducted by others such as First Responders or lay persons the quality and accuracy of information obtained from initial assessments may vary and the patient's condition can change rapidly especially in the case of severe burns remember it's the responsibility of you the provider and your team to perform your own thorough assessments and gather current data to make informed decisions about the patient's care and treatment plan the airway is a critical focus in Burn care demanding special attention due to the potential for inhalation injuries when burn patients are exposed to hot gases smoke particles and debris it can inflict harm on the delicate respiratory epithelium within just 2 hours of the injury inflammatory changes in the airway can become apparent leading to Bronco constriction increased mucus production and Airway swelling in cases where inhalation injury are suspected or confirmed healthc care providers should consider the use of Rapid sequence intubation as a vital intervention RSI involves administ in specific medications to induce rapid unconsciousness and muscle relaxation followed by otal intubation to secure the airway definitively this approach is key when burn related Airway damage compromises the patient ability to breathe adequately early intubation may be indicated in burn patients based on various factors and clinical signs these indications are essential for ensuring the maintenance of a patent Airway and adequate oxygenation and ventilation some of these examples are as follows patients with facial Burns especially those involving the nose and mouth are at risk of Airway compromise due to swelling and obstruction of the upper Airway the presence of Strider or Progressive heness can indicate narrowing or obstruction of the airway often due due to edema or injury of the vocal cords noticeable changes in the quality or pitch of the patient's voice may suggest Airway involvement and should be carefully assessed intraoral Burns can cause severe swelling and pose a risk to the patency of the airway burn injuries involving more than 40 to 50% of the total body surface area can result in systemic effects including Airway compromise difficulty in swallowing also known as dysphasia can indicate Airway involvement or injury to the structures of the throat any signs of Airway obstruction such as difficulty breathing retractions or audible respiratory noises warrant immediate evaluation and intervention other indications include patients showing signs of resp atory fatigue such as an increased work of breathing may require intubation inadequate oxygenation or ventilation can be indications for intubation patients who cannot manage their own secretions severe edema in the airway or patients with an altered mentation or impaired Consciousness as they may be at risk of Airway compromise burn patients are at risk of developing non-cardiogenic pulmonary edema a condition where fluid accumulates in the lungs due to factors other than heart rated issues this can result from inhalation injury where the airway is exposed to hot gases or noxious chemicals leading to Airway inflammation and fluid leakage into the lung tissue additionally fluid overload which may occur during resuscitation efforts May contribute to pulmonary edema appropriate oxygen therapy should be initiated early in order to ensure adequate oxygenation in burn patients however caution must be exercised when providing oxygen to individuals with COPD to prevent hyper oxygenation which can suppress their respiratory drive over long periods of time during the assessment of BM patients a thorough examination of the chest should include the search for circumferential Burns circumferential chest burns can cause restrictive chest movement and compromise ventilation reviewing arterial blood gas levels is an integral part of the breathing assessment in burn patients particular attention should be paid to the oxygenation levels to ensure adequate oxygen delivery to the tissues additionally measuring carboxyhemoglobin levels is essential especially if there is suspicion of inhalation injury as carbon monoxide poisoning can impair oxygen transport in the blood burn patients may also be at risk of pneumothorax or hemothorax due to chest trauma or Associated injuries in the context of burn patients it's important to be vigilant for signs of Co poisoning symptoms can include M to severe headache confusion dizziness weakness and in some cases loss of consciousness or Cardiac Arrest prompt attention to high flow oxygen therapy can displace Co from hemoglobin and improve oxygenation cyanide poisoning should also be considered in burn patients particularly if they exhibit specific clinical signs cyanide is released during the combustion of certain materials an inhalation can lead to cyanide poisoning signs of cyanide poisoning may include intense air hunger metabolic acidosis and sudden cardiovascular collapse in cases where patients have been involved in a confined space fire or exposed to conditions that could generate cyanide providers should be alert to the possibility of cyanide poisoning as early recogn and appropriate treatment such as administration of antidotes are essential to mitigate the potentially lifethreatening effects of cyanide toxicity burn injuries can lead to impaired cardiac output primarily due to the loss of fluid and electrolytes through the burned skin this of course can result in hypovolemia and reduced cardiac function therefore it's essential to closely monitor the patient's hemodynamic status Vital Signs and cardiac function when assessing circulation providers should thoroughly examine the extremities and digits for circumferential Burns which can lead to restrictive effects compromising blood flow to the affected areas early identification of circulatory problems such as compromised blood flow due to edema or vascular constriction is critical in order to prevent tissue necrosis and the potential need for amputation compartment syndrome can develop when EMA within a closed anatomical compartment compresses blood vessels and nerves leading to impaired blood flow the key symptoms include the five PS pain poar paralysis paresthesia and pulselessness coldness in the affected extrem remedy is sometimes considered a sixth symptom fluid resuscitation is a critical component of burn care providers typically use formulas such as the American burn Association or Parkland burn formulas to guide fluid administration these formulas are based on the patient's weight and extent of the burn injury and aimed to maintain adequate tissue profusion and prevent hypovolemic shock patients are risk of developing myoglobinuria a condition where the protein myoglobin is released into the bloodstream and subsequently excreted in the urine this can cause the urine to become very dark brown or even bloody and is often associated with muscle injury and contributes to kidney damage monitoring urine color is important for early",
        "Management": "detection management stopping the progression of a burn injury is the initial step in Burn management and several key measures are employed the first step is to remove the patient from the source of the burn to prevent further damage this may involve extinguishing Flames turning off chemicals or hot substances are simply moving the patient away from the Hazardous environment cooling the burn promptly is essential but it should be done cautiously the affected area can be gently irrigated with cool clean water for a duration of No More Than 3 to 5 minutes as this helps to dissipate heat and reduce tissue damage that being said cooling should not be excessive as overcooling can lead to hypothermia especially in large burns for chemical burns irrig ation is especially needed the irrigation process should continue until the burning sensation stops and the chemical material is completely flushed away this helps to neutralize and remove the corrosive substance minimizing ongoing tissue damage clothing and jewelry in the vicinity of the burn should be removed promptly as they can retain heat and exacerbate the injury removing these items also allows for more thorough assessment of the Burn's extent and depth after the initial cooling measures it's important to keep the patient warm to prevent hypothermia the patient should be placed in clean dried Linens to maintain body temperature and minimize the risk of infection these Linens should be sterile or at least clean to prevent contamination of the burn wound if an inhalation injury is suspected or confirmed and the patient's Airway is compromised or at a risk of deterioration providers may need to perform interrical Innovation or even surgical Airway interventions to secure the airway definitively in some cases particularly when the patient is hemodynamically unstable or agitated sedation may be necessary to facilitate the intubation procedure and ensure the patients comfort and safety during Airway management keep in mind sedation is not analgesia and if the patient is sedated it is not a bad idea to provide pain management for the patient during transport early assessment and appropriate intervention in cases of suspected inhalation injury May prevent further Airway compromise and distress in burn patients sual choline is a neuromuscular blocking agent commonly used for RSI in emergency situations however its use is contraindicated in specific circumstances related to burn injuries sual choline should not be administered to patients with burn injuries that are greater than 72 hours old in Burns of this age there's an increased risk of hyperemia sual choline can further raise potassium levels potentially leading to life-threatening cardiac arrhythmias in these patients rapdom myolysis is a condition where muscle breakdown products enter the bloodstream which can occur as a complication of severe burns sual choline is also contraindicated in patients with known rabdom mysis related to their burn injuries this can lead to elevated levels of potassium and myoglobin and sual Coline Administration can exacerbate these issues posing a significant risk to not only the patient's cardiac function but renal function as well in such cases alternative approaches to intubation should be considered non-depolarizing neuromuscular blocking agents like vecuronium can be used as alternatives to sual choline for intubation these agents do not have the same risk R of hyperkalemia and are suitable for patients with burn injuries older than 72 hours in situations where neuromuscular blocking agents are either contraindicated or simply not preferred providers May opt for Sedation only assisted intubation using medications such as automate or ketamine alternatively an awake intubation technique can be employed where the patient remains conscious and topical anesthesia is is applied to the airway to facilitate intubation while preserving Airway reflexes the choice of intubation strategy should be based on the patient's specific clinical condition and the presence of contraindications to sual Coline treating patients with suspected or confirmed exposure to toxic substances is important carbon monoxide poisoning can occur in patients due to smoking ation and reduces the oxygen carrying capacity of hemoglobin this fixation may result from smoke or lack of oxygen in a fire and as discussed previously cyanide poisoning can occur when certain materials combust to address these concerns the primary treatment for carbon monoxide poisoning asphixiation and cyanide poisoning is the administration of 100% oxygen this is typically provided via a non-b breathing mask or other high flow oxygen delivery system the flooding of 100% oxygen displaces carbon monoxide from hemoglobin restoring oxygenation which further supports cellular respiration in cases of cyanide poisoning supplemental oxygen assists oxygenating tissues despite the effects of the cyanide providers must work to maintain fluid balance and burn patients while fluid resuscitation is essential to address hypovolemia and prevent shock it must be managed judiciously to avoid complications from hypervolemia excessive fluid administration can lead to complications such as pulmonary edema abdominal compartment syndrome and electrolyte imbalances burn injuries can result in substantial intravascular fluid loss through multiple mechanisms the damaged skin in burn patients lacks its natural protective barrier making it susceptible to desiccation and excessive fluid loss through evaporation burn injuries also trigger an inflammatory response in the body which can cause the release of inflammatory mediators that increase capillary permeability this increased permability allows fluids to leak from the intravascular space into the interstial space leading to edema formation and further exacerbating hypovolemia effective fluid balance and burn patients involves closely monitoring fluid input and output adjusting fluid replacement to the patient specific needs and considering factors such as burn depth size and the presence of inhalation injury this approach helps to maintain adequate profusion while minimizing the risk of complications associated with either hypo vmia or hyperemia here are some key points related to fluid resuscitation deep second degree burns or larger especially when extensive result in hypotension due to the loss of intravascular volume as a result fluid resuscitation should commence promptly within 60 Minutes of the injury this rapid initiation is essential to prevent hypo shock establishing IV access is a priority in these patients in order to administer fluids and medications as needed ideally access should be obtained through the unburned skin areas to minimize the risk of infection that being said the American burn Association guidelines have evolved and the administration of fluids may not be recommended for patients with burn injuries requiring transport times of less than 60 Minutes as this will not allow for sufficient volume replacement when burn patients are expected to have an arrival time at the emergency department exceeding 60 Minutes lactated ringer solution is often the fluid of choice for resuscitation as this solution is a balanced electrolyte solution that helps restore electrolyte balance and intravascular volume the Parkland burn formula is a widely utilized form formula to guide initial fluid resuscitation in burn patients it calculates the total fluid volume required in the first 24 hours based on the patient's weight and the extent of the burn injury the formula takes into account the patient's estimated burn surface area and recommends a specific volume of lactated ringer solution to be administered over the initial 24-hour period with half the volume given within the the first 8 hours and the remaining half over the subsequent 16 the Parkland Vern formula is 4 CC's times the patient's weight in kilograms times the body surface area burned effective fluid resuscitation is essential to optimize tissue profusion preventing shock and minimizing complications in burn patients remember it should be tailored to the individual patients need and consider factors such as burn size depth and comorbidities while adhering to the evolving guidelines and protocols established by burn Care organizations after the initial steps of cooling irrigating and decontaminating the burn wound the provider should dry the area thoroughly once dry the wound should be dressed with clean dry dressings these dressings serve multiple purposes including protected the wound from further contamination in some cases bulky dressings may be applied to pad pressure points and sensitive areas around the burn wound these dressings help distribute pressure evenly reducing the risk of pressure sores or additional trauma while ointments and creams are generally unnecessary for routine burn wound care if they are already present on the wound due to Prior treatment they can be left in place it is important to ensure they do not become a source of infection and that they do not interfere with the assessment and management of the burn all burn wounds should be carefully examined to confirm the accuracy of the body surface area affected and the fluid resuscitation calculations accurate assessment is key to determine the extent of the burn in the appropriate fluid replacement volume debed which involves the removal of dead tissue should generally not be performed by Critical Care transport professionals unless specifically indicated by medical control such as in cases of chemical exposure or in blisters form due to chemical agents de brement is typically performed by Healthcare providers in a controlled clinical setting to ensure proper wound care and infection control in the case of tar or asphalt Burns as pictured here on the screen it's important to remove these substances from the wound because they can lead to infection and hinder the healing process aromatic hydrocarbons like Benzene tuline and nailene are effective for removing tar for asphalt removal nailene hexine and other carbon solvents can be useful it is important to note that these solvents used to remove tar and asphalt are toxic and should be used with caution following proper safety protocols in burn patients infections typically do not occur within the first few hours after the injury as a result there is no immediate role for antibiotic prophylaxis administered by Critical Care transport professionals during the initial stages of care however wound care and dressing application do play a pivotal role in infection prevention topical antibiotics may be used as part of the wound dressing to create a sterile environment and reduce the risk of bacterial colonization tetus is a potential concern in burn patients especially if the burn wound is contaminated with soil debris or other materials to address this patients who have not received a tetanus booster within the last 5 years should receive a dip theia and tetanus toxoid vaccine intramuscularly tetanus prophylaxis is essential to prevent this potentially life-threatening bacterial infection for patients who have not receive the primary series of three tetanus immunizations or whose immunization status is un certain TIG may be necessary in addition to the primary series of tetanus vaccinations as TI provides immediate passive immunity against tetanus and helps protect the patient while their immune system responds to the vaccine series pain control is of significant importance in the management of burn patients due to the excruciating nature of burn related pain here are some key considerations burns are associated with tense excruciating pain making effective pain management a top priority in Burn care opioid medications are often the Agents of choice for managing severe burn pain especially in patients without allergies to these drugs opioids provide potent analgesia and can help alleviate the severe discomfort experienced by burn patients alternatively medications such as fenil or Hydromorphone may be used in certain cases depending on the patient's individual needs in medical history continuous pain assessment and treatment are needed in Burn care pain levels should be assessed and addressed every 10 minutes until the patient reaches a comfort level of pain relief this frequent assessment ensures that pain control is maintained and that any changes in and pain intensity are promptly addressed it is also important to monitor the patient for signs of altered Consciousness as pain management may affect the patient's level of alertness providers should be cautious not to confuse sedation with analgesia while pain management aims to relieve discomfort without inducing excessive sedation the provider must strike the right balance to ensure that the patient remains comfortable while maintaining an appropriate level of Consciousness analgesia should be administered intravenously to ensure rapid and reliable absorption IV Administration allows for precise dosing and immediate onset of pain relief addressing the severe pain associated with the injury hypothermia can be a concern in burn patients due to the loss of the Skin's insulating properties provide ERS must measure the patient's body temperature before transport to identify any signs of hypothermia to prevent further heat loss wet clothing dressings and linens should be promptly removed from the patient as these items can contribute to Cooling and increase the risk of hypothermia dry sheets and blankets are preferred for maintaining the patient's body temperature within the normal range burn patients with a greater than 20% BSA affected are at risk of developing ilas a condition characterized by the loss of intestinal motility narcotic pain medications can further increase the likelihood of ilas in these",
        "Special Situations": "patients special situations renal failure and rapdom myolysis are medical conditions that can be associated with burn injuries inadequate urine output occurs in burn patients due to shock which can then lead to decreased kidney profusion impairing the kidney's ability to produce urine as stated earlier rabdom myolysis is a condition characterized by the breakdown of muscle tissue leading to the release of muscle proteins into the bloodstream these proteins can impair the filtration function of the kidneys potentially causing inadequate urine output it is more commonly associated with specific types of burn injuries including Crush injuries electrical Burns and large full thickness Burns these can result in muscle damage and the release of myoglobin in the bloodstream contributing to kidney dysfunction ocular burns are a significant concern in burn patients it is imperative that all burn patients undergo a comprehensive eye examination as this evaluation helps identify any injuries or damage caused by the burn corneal injuries can be excruciatingly painful to alleviate this pain opioids should be administered to patients with corneal injuries friction Burns which can result from Auto airbags blast injuries thermal Burns and chemical burns require thorough and prolonged irrig gration the affected eye should be irrigated with a copious amount of solution for at least 20 minutes or until the pH of the conjunctival sac returns to a neutral level of seven for irrigation Morgan lenses can be employed and topical anesthetics can be applied before lens placement to minimize discomfort lactated ringer solution ution is considered the optimal choice for irrigation though normal saline is also acceptable in cases involving critically burned patients with non-chemical ocular Burns topical opthamol preparations may be applied if the patient's clinical condition allows these preparations help support ocular health and comfort during the recovery process facial burns are associated with the heightened risk of eye and Airway injuries the proximity of the face to the eyes and Airways makes these areas vulnerable to burn damage and careful assessment and management of these issues are of utmost importance the face is prone to Rapid edema following burn injuries due to the rich network of blood vessels and lymphatics in the area to mitigate facial edema and reduce the risk of Airway compromise the head of the stretch stret should be elevated approximately 30\u00b0 as long as there's no suspicion of spinal injury this position promotes fluid drainage from the face which can help manage edema however this maneuver should be performed with caution and should not compromise the cervical spine in cases where spinal injury is suspected providers should conduct a thorough examination of the ear canal and eard Drum in burn patients before the onset of significant edema this early assessment allows for the detection of any potential injuries to these delicate structures and guides appropriate treatment pressure dressings should be avoided when managing ear burs instead large dry and bulky dressings should be employed the reason for this is because pressure dressings can exacerbate swelling and even compromise blood flow to an affected area additionally patients with ear burs should refrain from using a pillow this precaution helps prevent unnecessary pressure on the injured ear circumferential Burns that incircle the chest an extremity or the penis can lead to vascular compromise these Burns can cause constriction impairing blood flow to the affected area and potentially resulting in serious complications in cases where circumferential Burns threaten life or limb due to vascular compromise an escharotomy may be necessary this procedure involves making an incision through the stiff swollen burned area to restore Mobility to the chest or circulation to an extremity this procedure should only be performed in critical situations where it is vital to save the the patient's life or limb the decision to perform an otomy should be made in consultation with the Burn Center or the transport services medical direction as it is a delicate procedure that requires expertise in careful consideration of the patient's condition maintaining adequate blood circulation to the hands and feet is the utmost priority when managing Burns in the areas as impaired circulation leads to tissue damage and potential loss of function simple yet critical measures include elevating the affected hand or foot to reduce swelling in edema elevating the limb assists in improving Venus return and minimizes fluid accumulation additionally it's important to avoid constricting dressings or tight bandages it's important not to apply creams or ointments to burn injuries on the hands and feet as these substances can trap heat potentially worsening the burn and delaying the healing process furthermore they can increase the risk of infection in the burned area applying ice directly to burn injuries in the hands and feet should also be strictly avoided ice causes frostbite and instead the burn should be cooled with cool not cold running water for a limited duration while genitalia and perineum burns are significant concerns providers must prioritize and address life-threatening injuries first ensuring that critical conditions such as Airway compromise shock or inhalation injuries are managed promptly and effectively to facilitate urine trainings and prevent complications the early placement of an indwelling urinary catheter is is recommended as this helps maintain urinary function and minimizes the risk of urethal obstruction due to burn related edema a thorough examination of the penis is essential in cases of genitalia Burns particular attention should be given to assessing for circumferential Burns which can cause constriction and impair blood circulation monitoring for signs of compromised circulation such as discoloration or increase sensation is critical to prevent potential tissue damage or necrosis pediatric Burns and the potential association with child abuse present unique considerations in the realm of burn care and Child Protection children especially infants and young children have a higher ratio of surface area to body weight compared to adults this anatomical difference means that pediatric burn injuries can result in a relatively larger area of affected skin potentially leading to more extensive Burns infants have limited glycogen stores compared to adults in burn cases involving infants providers may consider administering glucose along with resuscitation fluids to ensure adequate energy supply for healing and Recovery shockingly a significant proportion of childhood Burns an estimated 25% are the result of child abuse accidental burns are more likely to occur on areas of the body commonly exposed to environmental hazards such as the face or chest providers should maintain a high index of Suspicion for child abuse when evaluating these injuries especially if the burn incident is not reported within the first 24 hours suspect Ed cases of child maltreatment including child abuse related to burn injuries must be reported to Child Protection authorities as well as the receiving Health Care Facility timely reporting is important to ensure the safety and Welfare of the child and to initiate appropriate investigations and interventions remember in all 50 states it is the responsibility of the primary care provider to report all suspicions of child abuse to the appropriate authorities electrical burns are a unique category of burn injuries that result from the passage of electricity through the body there are two different types of current AC is the most common type of electrical current found in homes and businesses and it is characterized by a regularly changing direction of flow such as that provided by standard household Outlets DC flows in a single Direction and is typically found in motor vehicle electrical systems certain Lighting systems and can also result from lightning strikes when electricity passes through or across a body it releases heat and this heat production leads to Burns the hands are commonly the point of entry for electrical current while the feet often serve as the exit point these Burns cause damage to deeper tissues and organs even when surface injuries may not appear severe therefore the extent of injury may not always be evident based solely on external findings electrical injuries can disrupt the normal electrical signals of the heart potentially leading to Cardiac Arrest Additionally the impact of electrical current on respiratory muscles can result in respiratory arrest due to the potential for Associated Trauma from Falls or muscle contractions it's important to employ spinal immobilization techniques and immobilize suspected fractures prior to Patient transport lightning strikes can result in extensive superficial cutaneous Burns that exhibit distinctive patterns often resembling ferns or reticular or net-like configuration again these Burns may appear less significant on the surface but can still have critical underlying tissue damage chemical burns can be caused by a multitude of substances commonly found in households Industries and Farms these chemicals vary in their composition properties and potential for harm which makes the assessment and management for chemical burns highly individualized unlike some other forms of burns that primarily affect the skin and underlying tissues chemical burns can pose an additional risk due to systemic absorption of the toxic substance some chemicals have the potential to be absorbed into the bloodstream leading to systemic toxicity and damage to internal organs prompt and thorough decontamination help mitigate this risk the immediate response to a chemical burn involves a removal of contaminated clothing and the irrigation of the affected area with copious amounts of water this process aims to physically flush the chemical away from the skin and minimizes contact Time providers and First Responders should never attempt to neutralize a chemical burn by introducing another chemical reactions resulting from neutralization attempts can be unpredictable and potentially exacerbate the injury instead the primary focus should be on removing the chemical through irrigation with water acid burns can occur due to contact with a variety of acidic substances commonly found in household Industrial and Commercial settings these include drain openers bathroom cleaners Swimming Pool Products rust removers and many others the severity of an acid burn can vary depending on the type and concentration of the acid the primary determinant of the extent of tissue damage from acid burns is a duration of contact between the acid and the skin or mucous membranes prolonged contact allows for the acid to penetrate deeper potentially causing more extensive damage rapid en copious irrigation with water is the initial and most critical step in managing these Burns this is because irrigation serves to dilute and physically remove the acid from the affected area some acids such as hydropic acid has specific mechanisms of injury that require special attention after initial irrigation providers need to apply topical calcium containing solutions to counteract the effects of these acids hydrop Floric acid in particular can lead to deep tissue injury and systemic toxicity if not appropriately managed Alkali Burns can occur due to contact with the range of alkaline substances commonly found in household industrial and construction settings these can include oven cleaners drain cleaners lime lie and cement the severity depends on the type and concentration of The Alkali in cases where exposure in involves dry powders or solid forms providers should brush away all visible dry powders from the affected area before initiating irrigation Alkali Burns require extensive and prolonged irrigation with flowing water to effectively neutralize and remove the substance irrigation should continue for more than 20 minutes to ensure thorough decontamination these Burns pose a significant risk to systemic toxicity similar to acid burns this is because alkaline substances can penetrate tissues and potentially lead to systemic effects including metabolic disturbances providers should be vigilant in monitoring patients with Alkali Burns for signs of systemic toxicity hydrocarbon burns are a specific category of chemical burns that result from exposure to substances containing hydrocarbon which are compounds of hydrogen and carbon atoms these burns are commonly associated with petroleum based products such as gasoline they are prevalent in various petroleum and petrochemical products including gasoline kerosene diesel fuel and other flammable substances management of these Burns primarily involves supportive care with the initial step being to remove contaminated clothing and thoroughly irrigating the affected area with copious amounts of water unlike some chemical burns there's typically no specific chemical neutralization required for hydrocarbon Burns exposure can have adverse effects on the cardiovascular system in particular some hydrocarbons such as gasoline have the potential to cause mardial depression leading to hypotension and cardiovascular collapse halogenated hydrocarbons are a subset of hydrocarbons that contain hogen atoms such as chlorine or Florine exposure to halogenated hydrocarbons may lead to fatal arhythmia these compounds can have toxic effects on the heart's electrical conduction system potentially causing Cardiac Arrest Steven Johnson syndrome and toxic epidural necrolysis are severe and potentially life-threatening skin conditions characterized by the Detachment and shedding of the epidermis these conditions are typically triggered by various factors including reactions to certain medications environmental allergens infections and sometimes by unknown toxins medications are among the most common culprits these include antibiotics insects heads anti-convulsants and some HIV medications environmental allergens and infections such as herpes simplex virus can also induce these conditions both Steven Johnson syndrome and toxic epidermal necrolysis are immune related diseases and they are considered hypers sensitivity reactions this means the immune system plays a key role in the development of these conditions leading to the severe skin and mucous membrane damage observed in affected individuals the immune response targets and then destroys cells in the epidermis resulting in extensive skin slopping the primary approach is supportive care these patients are typically already hospitalized and their care focuses on maintaining vital functions fluid and electrolyte balance and preventing more complication specialized Wound Care and Pain Management are also essential aspects of treatment in many cases these patients will require transfer to a burn center or a specialized Dermatology unit the skin is extremely fragile and prone to infection due to the loss of the protective epidermal layer dressings and topical ointments may be used to protect exposed areas promote healing and prevent infection these diseases are considered medical emergencies due to their rapid progression and potential for severe complications including sepsis and organ failure therefore prompt recognition the discontinuation of the triggering medication and immediate medical intervention will improve outcomes these conditions require multidisiplinary care involving dermatologists opthalmologists and Critical Care Specialists to provide comprehensive support to affected  individuals"
    },
    {
        "Introduction to Trauma Basics": "Trauma is a disease that harms or kills people during their prime years. In fact, you may know that the modern-day EMT was developed in response to this major cause of death on U.S. highways in the early to mid 1960s. While you have studied a wide variety of injuries in your EMT training, the ones that I focus on in this chapter are those that happen in the \u201ckill zone\u201d of the head, neck, torso, pelvis, and the upper legs. Although some of these injuries are obvious, others are hidden below the surface and require your detective skills to identify real or potential harm based on the mechanism of injury.",
        "Relating the Mechanism of Injury to Injury Patterns": "In trauma, determining the mechanism of injury (MOI) gives you a jump start in your assessment. Looking for clues as to the nature and amount of force involved in the event can help you predict what injury pattern you may find. The following sections define MOI in relation to force, describe different types of MOI, and show you how to match obvious injuries to hidden injuries caused by MOI.",
        "Connecting MOI and force": "A mechanism of injury is a description of a force that can cause an injury. Remember Isaac Newton and his three basic laws of physics? They may sound complicated, but in trauma they\u2019re pretty easy to understand.",
        "Differentiating blunt from penetrating MOI": "Although you may think there are lots of MOIs, they really boil down to two general forms: blunt and penetrating. Each has unique properties. In addition, you have to consider blast MOI, which is a combination of blunt and penetrating MOI.",
        "Blunt MOI": "Blunt MOI spreads its force over an area of the body. The skin may or may not be broken open, which can hide injury sites. You need to think beyond the surface and predict what injuries you may find in the following situations: Motor vehicle crashes: There are a few types of motor vehicle crashes (MVCs):",
        "Penetrating MOI": "Penetrating MOI concentrates its force into a specific area of the body, creating an opening through the skin. Examples of penetrating MOI include Gun shots: In gun shots, velocity makes all the difference. The faster the bullet, the more damage it can cause.",
        "Blast MOI": "Injuries sustained from an explosion have characteristics of both blunt and penetrating MOIs. Here\u2019s the progression: Primary blast wave: When the explosion first occurs, a wall of air pressure rapidly expands outward in all directions.",
        "Investigating Injuries That Affect the Airway and Breathing": "The following sections focus on injuries that require rapid identification and, in some cases, immediate action on your part. I am referring to conditions that either block (obstruct) the airway or somehow impair the patient\u2019s ability to breathe adequately.",
        "Injuries that block the airway": "No airway, no life; that\u2019s pretty much the message you hear all along in your EMT training. Table 12-2 lists key trauma reasons why an airway becomes blocked and what action you should perform to relieve the blockage.",
        "Injuries that make breathing difficult": "In order to survive, you have to maintain levels of oxygen and carbon dioxide no matter what. When a patient begins to fail at maintaining ventilation, you need to step in to supplement oxygen or take over ventilation; Table 12-3 details the action steps.",
        "Assessing Injuries That Affect Circulation": "The circulatory system is responsible for transferring oxygen, carbon dioxide, nutrients, and other wastes to and from every cell in the body. It does so through the interaction of its three major components: the heart, the vasculature (the blood vessels), and blood.",
        "Pump, pipes, and fluid: How circulation works": "Think about how water moves through your house or apartment. There has to be a pump that pushes water from your well or your town\u2019s water supply into the dwelling.",
        "Injuries to the heart": "The heart\u2019s function as a pump can\u2019t be overstated; even a small bruise can cause diminished cardiac output.",
        "Injuries to the vasculature": "Rising up from the left ventricle, the aorta is a very large artery that carries blood away from the heart to the rest of the body.",
        "Evaluating Spinal Cord Injuries": "Through much of the history of EMS, practitioners have been taught to immediately apply spinal immobilization to patients if the MOI could have caused a possible spinal cord injury.",
        "Managing Trauma Step by Step": "After you review various mechanisms of injury and the critical injuries they can cause (see the sections preceding this one), take a look at the following plan of action that can be used for any trauma patient:",
        "Practice Questions about Trauma": "The following practice questions are similar to the EMT exam\u2019s questions about trauma. Read each question carefully, and then select the answer choice that most correctly answers the question."
    },
    {
        "Definition and concepts": "Crush injury is the anatomical injury associated with direct trauma due to a compressive force. Extended entrapment with compression may cause crush syndrome, traumatic rhabdomyolysis, or compartment syndrome. Crush syndrome is the systemic manifestation of skeletal muscle injury from extended compression. Crush injury-induced traumatic rhabdomyolysis is one form of rhabdomyolysis; however, prolonged immobilization of an individual against a surface (e.g. due to altered level of consciousness) and agitated delirium can cause rhabdomyolysis without external trauma. Compartment syndrome is the increase in pressure within a fascial compartment eventually compromising venous outflow then arteriolar inflow with progressive capillary leak and edema leading to skeletal muscle injury that can progress to rhabdomyolysis. All three of these clinical entities may be encountered by EMS physicians, potentially in the same patient.",
        "Pathophysiology of crush injuries": "The systemic manifestations of crush syndrome are due to ischemia/reperfusion injury of skeletal muscle and the intense local and systemic inflammatory response due to the physiological, biochemical, and immunological changes that accompany the ischemic and reperfusion periods. Ischemia/reperfusion injury is encountered in EMS practice in acute stroke, head injury, myocardial infarction, and crush injury with crush syndrome. Reactive oxygen species and activated neutrophils are the main contributors to local and systemic effects of ischemia reperfusion. Oxygen is the substrate initiating this response and is provided upon reperfusion. All tissue is sensitive to ischemia reperfusion but skeletal muscle injury can cause major systemic complications. From the EMS perspective, the critical factors placing a patient at risk of crush syndrome are mass of muscle injured and ischemia time. The critical muscle mass necessary to put an entrapped patient at risk for crush syndrome is poorly defined, but qualitatively requires more than that of a hand or foot. Critical ischemia time is better defined but variable. At body temperature, critical ischemia time (the maximum time a tissue can tolerate ischemia and remain viable) of skeletal muscle is 4 hours. However, critical ischemia time can be shorter when direct trauma is the cause of ischemia rather than just vascular occlusion. The compression-stretch myopathy and ischemia of crush injury with muscle compression result in sarcolemma membrane leak and the release of myoglobin, urate, potassium, and phosphate out of muscle cells. Water, calcium, and sodium leak into muscle cells. Fluid and electrolyte shifts, myoglobinuria, and hyperkalemia then contribute to the systemic manifestations of crush syndrome after muscle compression is relieved and perfusion is reestablished. Large volumes of intravascular fluid shift into the injured muscle, leading to hypovolemia and hypotension. Hyperkalemia and metabolic acids cause bradydysrhythmias and reduced cardiac output while uric acid from muscle purines and myoglobin cause acute renal injury. From a clinical management perspective, the early consequences of crush syndrome are hypovolemia, hyperkalemia, and metabolic acidosis and the late consequence is acute renal failure due to myoglobinuria and uricosuria.",
        "Clinical setting": "Because the compression-stretch myopathy and reperfusion injury of crush injury that goes on to become crush syndrome requires muscle compression of the order of hours rather than minutes, the clinical setting of EMS patients in which crush syndrome is to be suspected will be somewhat unique. Mostly these patients will be entrapped in some way, requiring disentanglement and extrication involving technical rescue, or may require a search operation before extrication is possible. In single-patient or small multicasualty incidents this may involve traffic collisions, industrial, construction or machinery incidents, explosions, structural collapse, debris flows, and below-grade or confined space entrapments. Although the critical mass of skeletal muscle necessary to cause the systemic effects of crush syndrome is uncertain, the clinical setting would likely involve entrapment of an extremity, possibly as far as the shoulder, hip, or gluteus. Torso compression associated with traumatic asphyxia would be rapidly fatal. In the large multicasualty or mass casualty/disaster setting, crush syndrome is associated with structural collapse due to earthquakes, floods, tornadoes, hurricane/tropical cyclones, or events of war. Because substantial time might pass before survivors are found in search operations following a disaster, crush syndrome can be a major contributor to delayed morbidity and mortality. Crush syndrome that leads to acute renal failure has been reported to be the second most frequent cause of mortality following disasters, after direct trauma.",
        "Management of crush injury": "The field management of crush injury will depend upon the immediacy of disentanglement and extrication, extent of the anatomical injury, access to and availability of definitive health care infrastructure, transport time, number of casualties, scope of practice of field EMS providers, and availability of advanced field EMS response resources. Fundamentally, treatment begins with control of external hemorrhage and stabilization of orthopedic and soft tissue injuries following stabilization of the airway, assisted ventilation, and decompression of a tension pneumothorax as needed. Early and effective hemorrhage control can be life-saving. Following external hemorrhage control, stabilization of the soft tissue and orthopedic injuries through dressings and splinting will contribute to reducing any further injury during patient movement and to pain control. These interventions should not, however, independently delay transport to definitive trauma care, especially when the crush injury is part of other multisystem trauma. Pain management is both therapeutic and humanitarian during EMS operations. The operational use of analgesics in EMS is defined by two principal considerations: the analgesics available within the scope of practice of the EMS provider, and the spectrum of adverse effects as they relate to the patient and to the rescue environment. Opiates are a common and effective analgesic widely available within EMS practice. In the rescue environment one important consideration is respiratory depression. Access to and management of the airway may be limited during disentanglement and extrication of an entrapped patient, so escalating doses of opiates and their associated effect of respiratory depression must be considered. When scope of practice or availability of advanced EMS responders allows, adjunctive ketamine can be useful during EMS rescue operations. Ketamine in subanesthetic doses (0.1\u20130.2 mg/kg intravenous or intraosseous) as an adjunct to opiates can reduce the dose of opiates needed to achieve the degree of analgesia required to improve patient comfort and tolerance of movement necessary during the rescue evolution. During mass casualty/disaster operations, patient evacuation to definitive care can be delayed by hours or days. If there are open soft tissue injuries or open fractures, empirical antimicrobial therapy can be given. Literature on infection prevention, morbidity, and mortality following crush injury in disasters is lacking but pending clinical evidence, it is reasonable to administer intravenous or intramuscular antistaphylococcal antibiotics, and tetanus toxoid or tetanus immune globulin if those resources are available. Of note, soft tissue injuries with heavy soil contamination (e.g. injuries from tornado debris) have resulted in fungal infections and soft tissue injuries following improvised explosive devices with cross-contamination from bone and tissue of other persons will require HIV, HBV, and HCV prophylaxis and postinjury surveillance. During the field care of a rescued entrapped survivor, an extremity crush injury may begin to show signs of compartment syndrome. Compartment pressure measurement may not be practical, and the classic signs of pulselessness, pallor, paresis, paralysis, and pain out of proportion to injury are all late signs. If compartment syndrome is clinically suspected in association with crush injury in the mass casualty/disaster setting based upon mechanism of injury and pain on passive movement of a distal digit, the therapeutic decision is between adequate and monitored fluid resuscitation and field fasciotomy. Given the absence of outcome data on field fasciotomy and the risk of infection, nerve and other iatrogenic injury, it is likely better to address fluid resuscitation requirements and keep the affected extremity at heart level than to perform a field fasciotomy.",
        "Management of crush injury with suspected crush syndrome": "When extremity entrapment has been of the order of hours or longer, treatment extends to the prevention of morbidity and mortality from two additional mechanisms: sudden hypotension and cardiovascular collapse upon extrication, and late renal failure. In the individual patient or multicasualty setting, the duration of entrapment that puts the patient at risk for sudden hypotension and cardiopulmonary arrest has not been well established but traumatic rhabdomyolysis has been reported to occur in less than 1 hour. Myoglobinuric acute renal failure following rhabdomyolysis has been reported to occur in up to 33% of cases and to account for up to 50% of fatalities, and was prevalent following the earthquakes in Armenia, China, and Turkey. Morbidity and mortality from immediate postextrication hypovolemia and hyperkalemia as well as late myoglobinuric acute renal failure can be reduced through field interventions. When crush syndrome is clinically suspected during the management of crush injury, based upon time of entrapment and mass of skeletal muscle compressed, the principal intervention is intravascular fluid resuscitation. Substantial fluid shifts from the intravascular compartment to the interstitial and intracellular compartments during entrapment can result in a precipitous drop in blood pressure following disentanglement and release of the compressing force. A reduction in cardiac output can result from hypovolemia as well as dysrhythmias from hyperkalemia and metabolic acidosis when the injured extremity is reperfused. In single-patient or multicasualty incidents involving crush injury, access to the vascular space will be intravenous or intraosseous. Intraosseous vascular access will have to be in an ipsilateral or contralateral largely uninjured extremity. Proximal and distal long bone as well as manubrium access sites may be limited by local scopes of practice. If advanced practice EMS providers or EMS physicians are available, as well as during mass casualty/disaster events, then central venous access as well as hypodermoclysis (with or without hyaluronidase) may become options for intravascular volume resuscitation. From a medical logistics perspective, intravenous and intraosseous fluid resuscitation in the rescue environment is probably best done using intermittent bolus infusions. Depending upon the patient's physical position and confinement during entrapment, it may not be practical to hang intravenous solutions to be delivered by gravity, and intravenous infusion pumps may not be available. Pressure infusion bags are a consideration but are difficult to control. Additionally, there may be technical rescue operations going on in close proximity to the patient and intravenous lines, monitoring cables, and oxygen tubing are prone to cutting and dislodgment. Medical and rescue personnel will need to coordinate operations to keep the rescue effort moving. Well-coordinated drug and intravenous fluid bolus therapy along with interval patient assessment will help to optimize patient care as well as rescue operations. When intravenous or intraosseous vascular access is impossible and central venous access and hypodermoclysis are unavailable, then applying an arterial tourniquet close to the time of disentanglement and release of the compressing force may prevent sudden fluid and electrolyte shifts. Literature on the safety and efficacy of arterial tourniquets for this purpose is lacking, but they should be applied at any point when hemorrhage uncontrolled by other means is part of the problem. The endpoint of intravascular resuscitation is more difficult to define. Conceptually the goal is to maintain cerebral, coronary, and renal blood flow during the compartmental fluid shifts and/or hemorrhage associated with crush injury, crush syndrome, and extremity reperfusion. The difficulty is defining field-expedient measurable endpoints that reflect those goals. Currently heart rate and heart rate trends, target systolic blood pressure, and presence of pulse oximetry waveforms and measurements of waveform quality from digital capillary beds are practical measureable endpoints in EMS practice. Patient access may be limited if entrapment includes confined space operations. It is also conceivable to monitor urine output, or at least the concomitant occurrence of head injury, blunt and/or penetrating multisystem trauma, or underlying illness such as chronic heart failure or renal disease. The goal of maintaining end-organ perfusion is favorable when head injury and crush syndrome occur together. However, the strategy of permissive hypotension in penetrating trauma, and perhaps in blunt trauma as well, is in direct conflict with the strategy of intravascular fluid resuscitation for crush syndrome. Evidence-based composite endpoints for systolic blood pressure or other vital signs and fluid resuscitation for the comorbidities of head injury with penetrating or blunt trauma associated with crush syndrome have not been established. The other intra- and postrescue short-term risk in crush syndrome is hyperkalemia. Whether hyperkalemia evolves during the extrication or is a consequence of limb reperfusion following disentanglement and removal of the compressing force, it can result in bradydysrhythmias and, along with postextrication hypovolemia, contribute to sudden death. Therapeutic options for hyperkalemia will depend upon scopes of practice and availability of medical resources during the rescue. Maintaining perfusion with intravenous volume resuscitation is the essential therapy. A second generally available strategy is empirical treatment of metabolic acidosis or blood alkalinization using intravenous or intraosseous sodium bicarbonate (e.g. 1 mEq/kg intermittent bolus therapy every few hours). Although field-expedient point-of-care blood analyzers are available, measurement of acid-base parameters is usually limited to specialized medical resources that may not be part of the initial response. Another strategy would be to add 50\u2013100mEq of sodium bicarbonate to 1 liter of 0.45% sodium chloride, making it approximately isotonic, and use that solution for intravenous fluid replacement. Better goal-directed therapy would be possible if a point-of-care blood analyzer were available, or with continuous or intermittent ECG precordial lead V1 and V2 monitoring for T-wave shape and amplitude; however ECG monitoring for hyperkalemia lacks sensitivity and specificity. Hypotension in spite of intravenous volume resuscitation accompanied by atrioventricular block, tachycardia or bradycardia, or wide QRS complex ('sine wave' ECG appearance) would usually require intravenous or intraosseous administration of calcium chloride or calcium gluconate; however, in the setting of skeletal muscle crush syndrome, calcium is taken up by the injured muscle, making it difficult to raise blood calcium levels, and can aggravate the calcium-dependent apoptosis of myocytes. Another generally available treatment for hyperkalemia is inhaled beta\u2082-agonists like albuterol (e.g. 5 mg every few hours). Atmospheric monitoring and ventilation are important considerations if the rescue involves confined space operations and oxygen is used to drive a nebulizer. Compressed air (breathing air quality) is an alternative to oxygen if hypoxia by pulse oximetry is not present, and is more likely to be a renewable resource in the mass casualty/disaster setting. When available, a very effective treatment of hyperkalemia is intravenous or intraosseous glucose and regular insulin. This therapy requires frequent monitoring of blood glucose. Late morbidity and mortality from crush injury and crush syndrome can have many causes including sepsis, brain injury, and organ system failure from multisystem trauma. However, myoglobinuric acute renal failure can be prevented or can be reversed by renal replacement therapy (peritoneal dialysis, hemofiltration, or hemodialysis) when fluid resuscitation is begun prior to disentanglement and extrication. Early intravenous or intraosseous fluid resuscitation is the mainstay of treatment, along with empirical sodium bicarbonate to alkalinize the urine to protect the kidneys from the nephrotoxic effects of myoglobin and uric acid. When used early, mannitol, as both an osmotic agent and a polyalcohol free radical scavenger, can be nephroprotective by reducing interstitial fluid volume and muscle compartment pressure, thereby reducing release of myoglobin and purines, and by maintaining renal perfusion. Mannitol can be given alone (e.g. 0.5g/kg of a 20% solution) or 20\u201330 g of mannitol and 50\u2013100 mEq of sodium bicarbonate added to 1 L of 0.45% sodium chloride to be given as an infusion or intermittent boluses.",
        "Transport destination considerations": "Even in the absence of multisystem trauma, the potential for complex soft tissue, orthopedic, nerve, and vascular injuries resulting from crush injuries makes a designated trauma center the preferred acute care destination. Designated trauma centers will have access to the specialties of plastic and reconstructive surgery, microvascular surgery, and orthopedic surgery as well as critical care, nephrology, and infectious disease consultants. Depending on local standards of care, isolated extremity injury involving crush injury, compartment syndrome, or crush syndrome could be definitively managed at non-trauma-designated hospitals with access to specialty surgical and medical services, or could be stabilized and transferred to a referral hospital. Other than multisystem trauma and head injury, time-sensitive injuries associated with crush injury include uncontrollable External hemorrhage, vascular disruption or occlusion requiring surgical or interventional radiology vascular repair, and compartment syndrome requiring fasciotomy. Hyperbaric oxygen therapy has been used as part of the management of microvascular surgical repair of muscle flaps, partial traumatic amputations, vascular and ischemic muscle injury, but its efficacy has only been demonstrated in skin grafts and flaps and chronic ischemic ulcers in patients with diabetes. Hospital destination determination should be based on the availability of surgical and critical care resources rather than the availability of hyperbaric oxygen therapy."
    },
    {
        "Introduction": "Pain and suffering are not confined within hospital boundaries. Pain is a common complaint of patients cared for by EMS providers. It is estimated that 20% of the approximately 15 million patients transported by EMS annually in the United States experience moderate-to-severe pain. Although prehospital personnel are usually focused on the ABCs, the treatment of pain should be considered an important priority in the care of ill and injured patients. Most studies of EMS analgesia practices show that many patients with moderate-to-severe pain do not receive analgesia in the prehospital phase of their care. NAEMSP currently recommends that EMS systems have a policy to address prehospital pain management. The initial statement in NAEMSP position paper is, \u201cNAEMSP believes that the relief of pain and suffering of our patients must be a priority for every EMS system. Adequate analgesia is an important step for achieving this goal. NAEMSP believes that every EMS system should have a clinical care protocol to address prehospital pain management. Adequate training and education of prehospital personnel and EMS physicians should support the pain management protocol.\u201d Prehospital pain protocols should address the following issues. 1 Mandate for pain assessment 2 Tools for pain measurement 3 Indications and contraindications for prehospital pain management 4 Non-pharmacological interventions for pain management 5 Pharmacological interventions for pain management 6 Patient monitoring and documentation before and after analgesia 7 Transferring information to the receiving medical facility The challenge of treating pain in the prehospital setting is to use agents and techniques that are not only effective but safe and do not lead to physiological compromise or a delay in diagnosis upon arrival in the ED. Because of inordinate fears of and the desire to prevent side-effects, many EMS systems have opted for little or no use of pharmacological analgesics. Providing analgesia has been largely ignored in prehospital care education. Few EMS texts devote significant attention to this topic. Many systems do not have protocols to treat pain and suffering, other than that from ischemic chest pain. Many prehospital providers are frustrated by being unable to offer patients more than the \u201cbite the bullet\u201d approach to providing relief from acute pain. For those systems with reasonable analgesia protocols, the majority of patients are still untreated or undertreated. Many paramedic attitudes have been suggested as reasons for this inadequate treatment of pain. Prehospital pain management is a fertile area for study. Current research topics include barriers to prehospital analgesia, interventions to address barriers, non-opioid alternative analgesics (e.g. ketamine, IV acetaminophen), and alternative routes for pain relief, such as intranasal and transmucosal routes that can be used by basic providers as well as field-based ultrasound-guided nerve blocks that can be useful in wilderness settings or in prolonged extrications.",
        "Literature review": "Several studies have shown that oligoanalgesia is more the rule than the exception in prehospital care. One of the most dramatic studies was performed by White et al. in the city of Akron in the late 1990s. At that time, the EMS system had standing orders for either the administration of morphine sulfate, 2\u20135 mg IV push, or nitrous oxide, 50% self-administered. During the study period, 1,073 patients with suspected extremity fractures were identified. Of this large number of patients, only 18 received analgesia: 16 patients received nitrous oxide and two received morphine. McEachin reported on several different EMS agencies transporting patients to a single hospital in Michigan. Of 124 patients suspected of having lower extremity fractures, only 22 (18.3%) received parenteral analgesia. Many of these patients (38.4%) were triaged from an ALS response to a BLS transport. Hennes et al. reported results from prehospital analgesia practice in Milwaukee where a review of 5,383 patients with acute pain showed that morphine was administered in only 258 patients (4.8%). Of those patients with extremity fractures, 37 of 351 (10.5%) received morphine, and morphine was given to only seven of 258 children (3.0%). In patients with burn injury, 16 of 130 (12.3%) received morphine; only one of 12 children received it. Similar findings showing lack of analgesic administration or oligoanalgesia have been replicated in other studies. The benefits of prehospital analgesia are not only physiological. It improves the perception of quality of care provided by EMS. One study showed that 80% of patients reported the overall quality of EMS care to be excellent when they rated their pain management as excellent. Prehospital analgesia also dramatically decreases the time-to-analgesic administration, ranging from 60 to 120 minutes earlier, when compared to analgesic administration being deferred to the emergency department. Evans made the poignant statement, \u201cTo allow a patient to suffer unnecessary pain does harm to the patient \u2013 a violation of the first ethical principle of medicine.\u201d In a 1999 editorial, the late Peter Baskett states, \u201cThe blame for \u2018oligoanalgesia\u2019 must be laid at the door of physicians in authority who have, through ignorance, underplayed the physiologic and psychological benefits of analgesia and overplayed the potential of deleterious side effects of agents that are commonly available.\u201d",
        "Opioids": "Opioids are the best class of pharmacological agents to treat acute pain in all areas of medicine, including the prehospital environment. (See Box 67.1 for a list of desirable characteristics, most but not all of which are found in the opioids.) Osler referred to opioids as God\u2019s own medicine. The properties that make opioids desirable in the field include rapid onset, high potency, titrateability, relative safety, and reversibility. Morphine sulfate has been used for ischemic chest pain in the field for the past three decades. Over the past several years, fentanyl has gained increased usage. In many EMS systems, it is now the most commonly used opioid for non-cardiac pain. In emergency departments and in the field, it is increasingly replacing morphine for myocardial ischemia and chest pain. For many types of pain, opioids can be titrated by the IV route to produce safe and effective analgesia and can be administered by the intramuscular and intranasal routes as well. One of the major benefits of opioids is that most side effects can be rapidly reversed with an opioid antagonist, such as naloxone, which is carried by most EMS systems for use in opioid overdoses. With all opioids, EMS systems must adhere to Food and Drug Administration guidelines for monitoring and documenting possession and use. Specialized critical care transport teams seem to provide analgesia and achieve significant pain relief more frequently than described in routine ground-based EMS systems.",
        "Fentanyl": "Fentanyl has several properties that make it well suited for prehospital use. It is one of the only opioids that does not cause a release of histamine, thereby preventing potential exacerbation of reactive airway disease, and reducing the chance of inducing significant hemodynamic changes. Fentanyl is very lipid soluble, and it crosses the blood\u2013brain barrier quickly, reaching its peak effect within a few minutes. Its half-life is shorter than most other opioids with a duration of action less than 1 hour. Fentanyl does not cause any decrease in cardiac contractility. Like all opioids, however, it can decrease sympathetic tone and if a patient\u2019s blood pressure is dependent on the sympathetic nervous system, fentanyl can cause some hypotension, but this is relatively uncommon. Kanowitz reported on the use of fentanyl in 2,129 prehospital patients with an average titrated dose of 118 \u03bcg, with a range of 5 to 400 \u03bcg. Only 12 patients had any vital sign abnormalities during the drug\u2019s duration of action, and most of these were relatively minor, with only one patient receiving naloxone reversal. This one patient was an 83-year-old woman with a hip fracture who received two doses of 100 \u03bcg fentanyl and had some respiratory depression while in the ED that was immediately reversed with 0.4 mg of naloxone without any adverse effects. There were no significant complications or deaths as a result of prehospital use of fentanyl. The authors concluded that fentanyl effectively decreased pain scores without causing significant vital sign changes, thereby allowing it to be used safely and effectively for prehospital pain management. Several studies have also been reported showing the safe and effective use of fentanyl in ground and air transport of adult and pediatric patients. Fentanyl has a short half-life and duration of action of 60 minutes or less. Opioid-induced hypotension is rare with fentanyl, but in patients who are only able to maintain normal systemic pressure due to extreme sympathetic drive, fentanyl can blunt the sympathetic response and theoretically lower blood pressure. Should this occur, fluid administration is typically all that is needed, but alpha-adrenergic agents can be used to help to restore blood pressure. The safe and effective use of oral transmucosal use of fentanyl has been described in the battlefield setting. Fentanyl also has been used via the intranasal route through an atomizer device. In some systems, fentanyl is replacing morphine as the opioid of choice for ischemic cardiac chest pain.",
        "Morphine": "Morphine has been widely used in EMS systems for the past three decades. Initially it was largely restricted to the treatment of ischemic cardiac pain, but its indications have expanded to a wide variety of pain states. Despite the potential for a multitude of side-effects related to the prehospital use of morphine, the literature does not suggest that these have been a major clinical issue. Morphine has the advantage of having a wide margin of safety when it is used in careful IV titrated fashion. It is safe in patients with liver disease and for acute pain and can be used safely in renal disease. Morphine does not decrease cardiac contractility but does decrease preload and afterload and therefore should be used with caution in any patient who has borderline or frank hemodynamic instability. It is important to titrate the dose to the analgesia accomplished.",
        "Opioid agonist-antagonists": "Some characteristics of the opioid agonist-antagonist class of analgesics make them ideally suited for prehospital use. Drugs in this group include nalbuphine and butorphanol. The primary benefits of this class are the ceiling on respiratory depression, minimal euphoria and limited abuse potential, lack of biliary spasm, and minimal hemodynamic effects. Stene et al. described the prehospital use of nalbuphine in 46 patients with moderate-to-severe pain due to multiple trauma, burns, fractures, and intraabdominal conditions. The agent was partially to completely effective in 89% of patients and was without any major untoward effects. Nalbuphine also causes very minimal, if any, hemodynamic changes. Since that early study, others have confirmed the value of IV nalbuphine in the field. Another advantage of this drug is that it is not a controlled substance, easing some of the paperwork required when using morphine. Butorphanol is now available as a nasal spray. This agent and route of administration have many theoretical benefits in the prehospital environment, but studies have yet to be reported on the field use of nasal butorphanol. The use of the agonist-antagonist class of analgesics in the field may result in patients in the ED requiring somewhat higher doses of pure opiate agonists to achieve adequate analgesia.",
        "Nitrous oxide": "Nitrous oxide-oxygen mixtures fulfill many of the properties desired for a prehospital analgesic. Several field studies have demonstrated the safety and efficacy of self-administered 50% nitrous oxide in prehospital care. All studies have confirmed that the majority of patients with moderate-to-severe pain from a variety of sources will achieve significant pain relief. In unpublished data from use in the city of Pittsburgh in the past two decades, over 4,000 patients have been treated without any significant major adverse effects. Significant analgesia is achieved in approximately 80% of patients. In a rural EMS system, a nitrous oxide-oxygen mixture led to pain relief in 85% of patients for which it was used. One of the major advantages of the use of nitrous oxide is that it is relatively devoid of serious side-effects. Its major side-effect has been nausea, noted in four patients in a study by Ducasse et al., which also found that numerical rating scores decreased significantly with use of a nitrous oxide-oxygen mixture. In 1994, an alert entitled \u201cControlling exposure of nitrous oxide during anesthetic administration\u201d provided guidelines to prevent environmental levels from exceeding their recommended standards. In a moving vehicle, or one with a fan, short-term administration should be safe for the providers, although well-designed protocols must be written and followed when using this gas mixture. A prototype of a nitrous oxide protocol is shown in Box 67.2; it includes the absolute and relative contraindications to nitrous oxide administration. Recently, Australian authors conducted a systematic review of the safety literature related to the use of 50% nitrous oxide. They identified 12 randomized clinical trials investigating the use of 50% nitrous oxide compared with placebo. They conclude, \u201cNitrous oxide at a concentration of 50% is an effective and safe form of analgesia. The side effect profile of this agent suggests that it could be used by adequately trained laypersons in the prehospital setting. The question of nitrous oxide use by basic EMTs or by even lesser trained individuals such as rescue teams or ski patrol is a legitimate question, particularly in parts of the world where there is a dearth of prehospital advanced life support personnel.",
        "Ketamine": "Ketamine is a dissociative anesthetic that is structurally related to phencyclidine, and it has some unique properties. The dissociative state produced by ketamine is characterized by analgesia and amnesia, while preserving airway protective reflexes. Because ketamine is a bronchodilator, it can be used to treat severe asthma. It can be used as a field anesthetic for unusual situations, such as field amputations, dislocation reductions, or prolonged or complicated extrications. It has also been described as a useful agent for field surgical procedures during disasters, especially among children.\n\nAlthough this agent has had little indication for routine prehospital use, recently, at subdissociative dosages, it has been studied as a primary analgesic agent. The intranasal administration of S-ketamine has been described in Scandinavia. It has also been studied as an adjunct agent to decrease the dose of opioid needed to achieve pain relief in the emergency department. Polomano and others describe the use of low-dose IV ketamine in patients with pain from complex combat injuries, showing it to be safe and effective.",
        "Non-steroidal antiinflammatory agents": "Currently, few EMS systems routinely use aspirin or other nonsteroidal antiinflammatory (NSAID) drugs. Aspirin is now the standard of care as an antiplatelet drug in the treatment of acute coronary syndrome by field personnel, but rarely is aspirin used for pain management. NSAIDs are particularly well suited for treatment of ureteral and biliary colic. These drugs may also potentiate the analgesic action of opiates.\n\nAlthough these agents do not work as quickly as opiates, if given at the scene they will frequently have beneficial effects before the patient arrives at the hospital and definitely before the time that analgesic agents will be administered in the hospital. These agents should not be considered as a substitute for opiates and nitrous oxide but as another helpful adjunct with selected indications. The major side-effects to consider with a single-dose use in the field would be allergic reactions and platelet inhibition. They should therefore be withheld in the field if the patient has known allergies to NSAIDs or if the anti-platelet effect may exacerbate an underlying problem.",
        "Acetaminophen": "Acetaminophen is rarely carried on ambulances or used in the prehospital setting. Acetaminophen, like the NSAIDs, is an effective analgesic, especially in combination with opioids. One potential side-effect, although not likely after a single dose in the field, is the exacerbation of asthma. It is also well known to precipitate acute hepatic failure in patients with underlying liver disease or as a cumulative dose. A single dose in the field is unlikely to lead to acute hepatic failure, but caution would still be advised in these patients. Intravenous acetaminophen is increasingly being used in the hospital and has been studied in the postoperative setting.",
        "Communication techniques": "The most ignored aspect of providing prehospital relief to those with pain and suffering is the powerful effects that can result from therapeutic communication techniques. These techniques can be mastered by all providers and can bring a significant degree of comfort to patients without use of pharmacological agents. Jacobs points out that many patient responses to an injury or illness are occurring at an unconscious level and that every word, phrase, sentence, pause, voice inflection, and gesture can initiate automatic psychophysiologic effect. An example of a suggested dialogue for a patient with burns is as follows. I'll bet you can imagine some place you'd rather be than here. As a matter of fact, go ahead and do that now while we get you bandaged up. Think of your favorite place. When you are there in your mind's eye, look around and notice all the things there are to notice. Listen to the sounds. Feel the good feelings. There might even be a special aroma you can smell. When you are really experiencing that place, let me know by raising your index finger. Good. Although many prehospital providers may feel uncomfortable with guided imagery techniques such as this, they all should recognize the powerful implications of their verbal and non-verbal communication. Providers should be capable of engaging patients in a way that distracts them from their injury or illness. Distraction can also be very helpful while prehospital providers are performing potentially painful interventions, such as starting an IV line or splinting a fracture. Music has been shown to be effective in decreasing the pain of laceration repair in EDs and could be adapted for use on an ambulance. Words should be chosen carefully when communicating; mild discomfort is more useful than terms such as bee sting, prick, or shot.",
        "Assessment of pain": "Objective assessment of pain can be difficult because it is a subjective symptom. The degree of pain cannot be gauged simply by observing vital signs or facial expressions. The pain literature repeatedly documents the unreliability of both vital signs and facial expression in assessing the severity of pain. For pediatric patients, EMS providers often underestimate pain. However, easy-to-use tools are available for adult and pediatric patients that are based upon patient self-report. According to NAEMSP position statement \u201cPrehospital pain management,\u201d self-report scales are \u201cthe most reliable indicator of pain.\u201d These scales allow not just the quantification of pain at one point in time, but also for monitoring the change in the level of pain over time and after analgesic administration. A helpful technique is to use a 1\u201310 (\u201cno pain\u201d to \u201cunbearable pain\u201d) numerical rating scale (NRS), which is a completely verbal scale. This scale is very easy to use for patients who can speak and are fluent in the same language as the prehospital provider. Alternative scales include the verbal rating scale (VRS) and visual analog scale (VAS). These scales require printed diagrams so are more cumbersome. However, they can be useful for patients who are unable to speak or who are fluent in languages other than that of the prehospital provider. The instructions and diagrams for these two scales can be preprinted in any language. The VRS has five listed pain levels and the patient is asked to pick the one that describes his or her pain. The VAS has a line that is 100 mm long, with \u201cno pain\u201d listed on the left and \u201cmaximal pain\u201d written on the right. The patient is asked to indicate where along the line his or her own pain level lies. According to \u201cPrehospital pain management,\u201d one-dimensional pain scales that can be used for pediatric patients include the Color Analogue Scale (in which colors indicate the intensity of pain) and the Faces Pain Scale (in which cartoon facial expressions indicate the intensity of pain). The Faces Pain Scale also may be useful for non-English-speaking patients or those with limited English comprehension skills.",
        "Pitfalls": "The major pitfall regarding analgesia is the attitude that it should not be provided in the field but should wait for hospital evaluation. Safe and effective prehospital pharmacological analgesia should be delivered as soon as possible and non-pharmacological techniques are appropriate for the majority of patients with pain. These techniques will not \u201cmask\u201d the diagnosis or worsen the patient\u2019s condition. Pain is subjective and should be measured by the patient\u2019s words and not expectations of how much a patient should be suffering for a given condition. Another pitfall is to believe that there is a \u201cuniform\u201d dose of analgesic that will bring elimination of pain when using pharmacological therapy. Particularly with the use of opioids, there is tremendous interpatient variability. The best way to approach pain control is to titrate the medication, monitoring for side-effects and efficacy, until the desired result is reached. A particularly common pitfall is the belief that the degree of pain can be gauged by vital signs or facial expressions. The pain literature repeatedly documents the unreliability of either vital signs or facial expression in assessing the severity of pain. The only scale that should be used is verbal expression. A helpful technique to use is a 1\u201310 verbal analog scale, with 10 representing the worst pain the patient has ever experienced. For pediatric patients, using other methods, EMS providers underestimate pain. Another pitfall is to fail to distract the patient while performing painful procedures. Just the opposite usually occurs, with the provider calling attention to every step of the procedure, using terms that are intended to soften the insult but usually actually magnify it. Studies have identified many barriers to prehospital analgesia. These include lack of \u201csignificant objective signs,\u201d concern for malingering, aiming simply to \u201ctake the edge off,\u201d and concern about administering dosages of morphine greater than 5 mg. Specifically in pediatric patients, unfamiliarity with pediatric patients and protocols, insufficient education in pediatrics, difficulty in medication administration in uncooperative pediatric patients and inability to assess pain in children have been reported as barriers to analgesia. Protocol changes have been attempted as a means to improve prehospital analgesia rates by removing protocolized barriers, such as the need for a medical oversight order or restrictive assessment categories (e.g. only allowing analgesics for extremity injury or cardiac chest pain). Removing the need for medical oversight order has been found to increase time to analgesic administration. Neither of these protocol changes has been shown to increase the number of patients receiving analgesia to any clinically important amount. The lack of efficacy of these changes is not surprising considering that they do not address the identified barriers to prehospital analgesia. However, educating prehospital providers about pain management may be a more efficacious route to improving prehospital analgesia because such interventions can address the barriers to analgesia. This has been proven to be the case in multiple studies, showing improved understanding of pain management principles and a significant improvement in prehospital pain treatment after educational interventions.",
        "Conclusion": "Treating acute pain and relieving suffering should be a primary mission of all health care providers. Unfortunately, EMS personnel have not been given the tools or training to satisfactorily accomplish this worthy goal. Although patient \u201csafety\u201d and \u201cdoing no harm\u201d must always be considered, these should not be used as excuses for \u201cdoing no good\u201d for patients with acute pain treated in the field."
    },
    {
        "Introduction": "Trauma is the leading cause of death for North Americans aged 1\u201334 years, only surpassed by cancer and cardiovascular disease in older adults. Penetrating trauma has significant morbidity and mortality and is a common cause for activation of EMS. Injuries due to firearms are particularly lethal and require rapid assessment and decision making in the field to mitigate injury. In 2009, approximately 700 deaths in Canada were associated with firearms, 75% of which were intentional self-harm. In 2010 there were approximately 31,000 firearm-related deaths in the United States, of which approximately 61% were suicides. Other potential causes of penetrating trauma include knives, arrows, nails, glass, wood, and wire. Penetrating trauma can also occur with shrapnel from explosions as well as with foreign objects flying in motor vehicle collisions. The types of weapons/projectiles, the way in which the object imparts its energy, as well as the location of impact, dictate the type and severity of injury.",
        "Physics and mechanics of penetrating trauma": "Two physical concepts explain injury associated with penetrating trauma. The energy associated with a moving object is defined by: kinetic energy = \u00bd mass \u00d7 velocity\u00b2. Kinetic injury explains why a small and light projectile (e.g. a bullet) can result in devastating injury. Because the projectile energy is related to the velocity squared, doubling the velocity results in a four-fold increase in kinetic energy; if velocity increases by a factor of 4, kinetic energy increases by a factor of 16. In penetrating trauma, the projectile imparts kinetic energy to the victim\u2019s body, resulting in injury. The second concept is the Law of Conservation of Energy: Energy cannot be created or destroyed but only transferred from one form to another. When a projectile enters the body and remains there, it can be inferred that all the projectile\u2019s kinetic energy has been transferred to the body. Where the projectile travels through the body and exits, the energy transferred to the body is equal to the kinetic energy of the object before entering minus its energy on leaving the body. Weapons can usually be classified based on the amount of energy carried by the projectile. \u2022 Low energy: knives, hand-launched missiles \u2022 Medium energy: handguns, smaller bullets, lower velocities (200\u2013400 m/s) \u2022 High energy: military or hunting rifles, larger bullets, higher velocities (600\u20131000 m/s)",
        "Ballistics": "Ballistics, the study of projectiles as they move and hit their target, includes trajectory (the path that that an object follows after launch) and terminal ballistics, a more clinically relevant measure which reports how the projectile acts when it hits its target. Several factors affect terminal ballistics, including missile size, velocity, missile shape, deformity, and stability.",
        "Size": "As a general rule, the larger the missile, the more damage caused by direct contact between the missile and tissue. Larger missiles generally have a greater surface area and impart more energy faster. Bullet size is measured by the inside diameter of the gun barrel either in millimeters (e.g. 9 mm) or hundredths of an inch (e.g. 44 caliber). Magnum rounds refer to those with more gunpowder than a normal round, which increases the muzzle velocity and thus the bullet energy by 20\u201360%.",
        "Velocity": "Missiles traveling through air encounter resistance or drag. Drag increases exponentially with velocity and is inversely proportional to mass. Clinically, this implies that the damage caused by a missile at short range will be greater than one fired at longer range and that heavier missiles are able to maintain their velocity better than light ones. For practical purposes, the impact velocity of bullets will be the same as the muzzle velocity at 45 meters for low-energy firearms, such as handguns, and 90 meters for higher velocity weapons, such as rifles. Slower-moving missiles such as knives or arrows have less kinetic energy and cause injury only where in contact with tissue. Higher energy missiles, such as rifle bullets, create a shockwave and a cavity in the body tissues. This process is known as cavitation.",
        "Shape and deformation": "The energy imparted by a missile is related to its shape. Missiles that are blunt (i.e. have a higher cross-sectional area) experience more resistance and impart energy to tissues quickly, whereas sharper missiles cut through tissues more effectively and release energy over a longer period of time and distance. Projectiles may deform on impact, increasing the bullet's cross-sectional area. This mushrooming effect raises the resistance between the missile and tissues, thus increasing the energy transfer rate. Some missiles may fragment on impact, increasing the rate of energy exchange because the total surface area of the fragments is greater than that of the original missile.",
        "Stability": "Contrary to popular belief, bullets often do not travel in a direct line and may tumble or wobble (yaw) in their course, often decreasing the velocity and accuracy of the missile. If it tumbles or yaws after hitting tissue, the bullet's surface area with respect to tissue is increased, thereby increasing the amount and rate of energy transfer and thus the extent of injury.",
        "Types of weapons - Knives and arrows ": "Knives and arrows are considered to be low-energy weapons. Although the projectile's weight may be significantly higher, the velocity is generally much lower. Tissue damage is typically restricted to direct contact between the projectile and tissue. The extent of tissue damage can be extremely difficult to estimate because the projectile's trajectory cannot be determined based on external injury appearance. The entrance wound will not predict whether the object moved around within the body or what organs it came into contact with. It is, however, useful to know the blade length; to a certain degree this can predict the maximum depth of penetration.",
        "Types of weapons - Handguns": "Handguns are typically short-barreled, medium-energy weapons with small bullets. As a medium-energy weapon, a handgun's damage-causing potential is more limited than that of higher energy firearms. Handgun bullets tend to have a blunter shape, causing early release of energy. Despite their shape and composition of softer metal (lead), handgun bullets tend not to deform due to their lower energy. As such, the bulk of the injury is caused in tissues damaged by the bullet's passage.",
        "Types of weapons - Rifles": "Rifles are named for the rifling in the barrel, which causes the bullet to spin. The spin of the bullet improves accuracy and range due to the conservation of angular momentum. Rifle bullets are larger, retain more kinetic energy, and travel much further with greater accuracy than do handgun projectiles. They are able to transfer significant energy with damage extending outside the bullet's immediate track. Hunting ammunition is designed to expand dramatically (up to three times) on impact, increasing the speed of energy delivery and the wound pathway. Military ammunition is fully jacketed so it does not deform, which decreases the energy delivery rate.",
        "Types of weapons - Shotguns": "While shotguns can fire single bullets (slugs), in general they fire a collection of spherical pellets, called shot, which radiate from the muzzle of the gun in a conical distribution. Typical muzzle velocity is 360 m/s. Shot have a high drag coefficient so they lose velocity quite rapidly. At short range, they can be devastating but at longer range they lose much of their destructive potential.",
        "High-velocity projectile injury": "While low-velocity projectiles inflict injury by direct cutting or tearing of tissues, higher velocity projectiles inflict injury in three ways: direct, pressure wave, and cavitation.",
        "Direct injury": "Direct injury is caused by a projectile\u2019s impact including crushing and lacerating tissues. Direct injury is based on the projectile size, although this may be modified by any deformation and bullet instability as it travels through the body. Crushing and laceration cause serious injury only if the bullet strikes organs or blood vessels. Body armor protects the wearer by spreading the energy of impact over a larger area. Although this means that the projectile is prevented from hitting the body, the kinetic energy strikes a larger area, which can cause significant injury, such as fractured ribs and cardiac contusions.",
        "Pressure wave": "When a high-velocity projectile (greater than 750m/s) hits human tissue, a high-pressure wave moves outward from the missile track in all directions. Caused by the compression ahead of the bullet, the pressure wave moves faster than the bullet itself. The faster and blunter the projectile, the greater the effect. Pressure from higher velocity bullets can exceed 1,000 pounds per square inch. Pressure waves travel better through fluids, higher density tissues, and organs, causing tearing and crushing of tissues. Blood vessels and solid organs (e.g. liver or spleen) can be injured or in some cases fractured. Hollow organs (e.g. large bowel) can rupture, and bones can be broken by the pressure wave.",
        "Cavitation": "High-velocity projectiles create a temporary cavity behind the missile path as tissues move away from the track. Cavity size is dependent on energy transferred during the bullet\u2019s journey and may be 30\u201340 times the diameter of the bullet. The cavity will have a lower pressure than the air outside the body, causing air and potentially debris to be pulled in through the entrance and exit wounds. After the bullet has passed, the elasticity of the surrounding tissues tends to collapse the temporary cavity.",
        "Entry and exit wounds": "Bullets often have both entry and exit wounds. In general, the exit wound is the same size or larger than the entrance wound but this is not always the case. Although bullets typically follow the path of least resistance, they may not travel in a straight line. Projectiles may have an unpredictable path within body tissues, including rotation or ricochet and deflection off bony structures. Two injury sites do not always represent an entry and an exit wound as they may represent two different entry wounds. Entrance wounds can be deceptively small. A very small entrance wound can hide a devastating injury, and EMS providers should not be lulled into a false sense of security by a small entrance wound.",
        "Resuscitation and initial assessment": "Although the standard approach to patient assessment is described elsewhere, there are several unique considerations in the patient who has suffered a penetrating injury.",
        "Scene safety": "Although a thorough assessment of scene safety is always a priority, it takes on particular importance when dealing with penetrating trauma. Almost all potential causes of penetrating trauma harbor risks to the unwary EMS provider, and these must be considered before scene entry. When penetrating trauma is a result of assault, the prehospital provider must ensure the perpetrator is no longer in the immediate area or has been apprehended or restrained by police. On other scenes where penetrating trauma is a possibility, such as explosions or motor vehicle collisions, the EMS personnel must examine the scene before entry to ensure there is no undue risk. When the scene is unsafe, the provider should withdraw to a safe distance and summon the appropriate assistance, such as police or fire services.",
        "Spine immobilization": "Assessment for possible spinal cord injury is important. Numerous case series have challenged the need for spinal immobilization in penetrating trauma patients. It is well accepted that cervical spine (c-spine) immobilization is not required for penetrating firearm injuries to the head. Similarly, immobilization for penetrating injuries to the neck and torso is likely only required when there is a high suspicion in an obtunded patient or obvious neurological compromise.",
        "Extremity bleeding": "Most bleeding from extremities, including arterial bleeding and amputations, can be controlled with direct pressure and elevation of the wound. When extremity bleeding persists despite these maneuvers, it may be necessary to apply a tourniquet. Persistent bleeding when constant direct pressure cannot be maintained, such as military-casualty incidents or tactical environments, may also necessitate a tourniquet. Military use of tourniquets has undoubtedly saved lives in combat situations. Similarly, tourniquet use during the Boston Marathon bombing in 2013 allowed over 200 injured patients to be promptly treated and transported to area hospitals. This is discussed more fully in Volume 1, Chapter 35. The letters TK and the time the tourniquet was applied should be written on the patient\u2019s limb or forehead.",
        "Permissive hypotensive resuscitation": "In managing penetrating trauma patients, IV fluid therapy is controversial. Permissive hypotensive resuscitation advocates that only patients without radial pulses or with a systolic blood pressure (SBP) of <70 mmHg receive fluid resuscitation in the field. IV access should rarely be obtained on scene and should be reserved for en route in the upper extremities if possible. IV or IO access in the lower limbs is relatively contraindicated because abdominal vascular injuries may lead to direct extravasation rather than reaching the central circulation.",
        "Impaled objects": "In general, impaled objects are not removed in the field as the object may be providing tamponade to bleeding soft tissues and blood vessels, and removal could cause exsanguination. Because movement of the object may cause further injury, the object should be well stabilized with bulky dressings and tape. Occasionally this will require cutting the object to a shorter length on scene if it impedes extrication and transportation. Care should be taken to ensure minimal movement of the object during this process. The exceptions are removal of an object that impedes CPR in a pulseless patient or impedes airway management where airway control is required.",
        "Transport issues": "An optimized and efficient trauma system is required to deliver a patient from injury location to definitive care through a coordinated system of public access (9-1-1), EMS care, trauma triage, and trauma center. The corollary to the \u201cgolden hour\u201d for the trauma system may be called the \u201cplatinum 10 minutes\u201d for EMS, where the goal is to begin transport of the patient within 10 minutes of arrival on scene, barring extrication or other logistical issues that prevent prompt transport. The platinum 10 minutes, or \u201cscoop and run,\u201d is important in penetrating trauma patients who meet trauma triage criteria in which surgical management is likely. The term refers to the strategy of rapid assessment and transport. Interventions such as IV cannulation should be initiated en route to the hospital except in extenuating circumstances, such as a prolonged extrication. Conversely, the term refers to on-scene stabilization and initial management, which is rarely indicated in penetrating trauma. For the penetrating trauma patient in cardiac arrest, emergency department thoracotomy may be useful if performed within 15 minutes of loss of circulation. EMS providers should focus on maintaining the airway, good CPR, and correcting reversible causes of arrest, specifically hypoxia, tension pneumothorax, and hypovolemia, while transporting the patient to the hospital. Communication with the receiving ED or trauma center to notify them of the incoming patient, relevant injuries, and an estimated time of arrival is essential.",
        "Penetrating chest trauma": "The consequences of penetrating trauma depend on the mechanism and location of injury, the path of the projectile, and the underlying health of the patient. All patients with penetrating intrathoracic injury are at risk for intraabdominal or neck injury, depending on the entry point and path of the projectile. It is also true that a penetrating traumatic injury to the neck or abdomen can have associated chest injuries. When patients have been stabbed, it is useful to know the approximate length of the blade to understand what structures may have been injured. In the setting of a gunshot wound, any entry wound that does not have an exit wound should be considered to have retained bullet fragments.",
        "Lungs and bronchial tree": "Penetrating injury to lungs or bronchial tree can lead to escape of air or blood into the thoracic cavity, resulting in simple pneumothorax, tension pneumothorax, or hemothorax. Treatment for simple pneumothorax is supportive, for tension pneumothorax chest decompression may be required, and hemothorax should be treated with fluids, oxygen, and transport.",
        "Heart and great vessels": "Penetrating injury to the \u201ccardiac box\u201d increases the likelihood of myocardial and great vessel injury. The cardiac box is a rectangular shaped area of the anterior chest bounded superiorly by the clavicles, laterally by the midclavicular lines, and inferiorly by the costal margins. It should be noted that the cardiac box includes the epigastric area. Pericardial tamponade is a potentially rapidly life-threatening condition resulting from accumulation of fluid in the pericardial sac. It occurs more frequently in stab than gunshot wounds: 60\u201380% of stab wounds involving the heart develop tamponade. Only a small amount of blood (50\u2013100 mL) is necessary for pericardial tamponade to develop. Signs and symptoms of pericardial tamponade are hypotension, tachycardia, muffled heart sounds (Beck triad), dyspnea, cyanosis, and distended jugular veins. These signs may be followed by cardiac arrest with pulseless electrical activity. The treatment for pericardial tamponade is pericardiocentesis (potentially performed by the EMS physician in the field, particularly if ultrasound guidance is available) as a temporizing measure, followed by surgical repair. Any penetrating thoracic or abdominal trauma can cause a diaphragmatic injury. Because diaphragmatic injuries can result in significant respiratory compromise, respiratory distress associated with injuries to the chest or abdomen should prompt EMS personnel to consider the possibility of a diaphragmatic injury.",
        "Penetrating abdominal trauma": "Gunshot wounds to the abdomen most commonly injure the small and large bowel because of the large space they occupy. A projectile passing through a gas-filled bowel will often cause compression of that gas, which may limit the pressure wave and injury. However, a projectile passing through a solid organ, such as the liver and spleen, causes cavitation and more widespread injury. Penetrating abdominal trauma may cause devastating injury to the large vessels (i.e. aorta, inferior vena cava, iliac vessels), leading to immediate exsanguination and death. Due to the relative lack of skeletal protection and highly vascular structures, penetrating abdominal trauma has a high mortality. As opposed to blunt trauma in which force is more diffuse, transmitted across the abdomen, and leads to primarily solid organ injury, penetrating trauma is often a locally applied force affecting the hollow organs and mesentery. Solid organ injuries are less common with penetrating than blunt trauma, but they can occur, especially in stab wounds, with devastating consequences. Penetrating wounds should be covered to decrease infection and observed for ongoing bleeding. Any intraabdominal organs visible (evisceration) should simply be covered with sterile saline-soaked dressings and in turn covered with an occlusive dry or plastic dressing.",
        "Penetrating neck trauma": "Penetrating neck wounds can be immediately fatal, and seemingly \u201cinnocuous\u201d wounds can suddenly become life-threatening. Even the seemingly \u201cbenign\u201d penetrating injury to the neck should be treated with careful and expectant management. Injury to the major blood vessels of the neck may rapidly lead to exsanguination or delayed hemorrhage. Because of the thin overlying muscles and subcutaneous tissue, airway injuries to the larynx or trachea are common and may be devastating. Although somewhat protected by other structures, deeper injury can lead to pharyngeal and esophageal injuries. Lastly, neurological injury can occur to the spinal cord posteriorly, the cranial nerves superiorly, or the brachial plexus inferiorly. Common carotid injuries occur in approximately 10% of all penetrating neck trauma. Significant carotid artery injuries are usually rapidly fatal, but may occasionally tamponade briefly to allow transport and assessment. History of significant blood loss either at the scene or ongoing is evidence of a major vascular injury. Similarly, expanding hematomas may initially be subtle, but are signs of vascular injury and may lead to airway compromise from direct compression. Hematomas are often visible when the patient\u2019s head is in a neutral position and the patient is examined from the feet. Jugular vein injuries may also be fatal, but they may be successfully managed with direct pressure in the field to allow transport to an operative setting. Venous injuries may be complicated by entrainment of air leading to air emboli, a potentially fatal complication. Neurological deficits should be carefully documented and relayed to the receiving facility. Unilateral stroke symptoms may be related to carotid artery injury and subsequent brain ischemia. Additionally, unilateral cranial nerve and brachial plexus injuries may also be apparent as facial or arm weakness respectively. Spinal cord injury may result in unilateral or bilateral motor deficits of the arms and legs. Penetrating neck trauma can lead to airway anatomy distortion due to either a primary direct airway injury or secondarily via compressing hematomas and bleeding. Signs of an expanding hematoma, hoarse voice, stridor, airway compromise, or blood in the airway are warning signs of impending airway compromise and require quick action. Airway compromise should be anticipated, intubation should occur early rather than late, and in most cases, rapid transport should be initiated to a trauma center with basic airway maneuvers if airway intervention is not immediately required. Although prehospital providers are accustomed to considering a potential spinal injury and providing immobilization to the majority of blunt trauma patients, this is not always required in penetrating injury. Based on case reviews, many have advocated against immobilizing patients with penetrating neck injuries unless neurological signs or symptoms are apparent. Isolated stab wounds to the neck are unlikely to cause unstable cervical spine injuries. Although gunshots can lead to cervical spine injury, most spinal cord injuries are complete and obvious on initial evaluation, prompting immobilization. The provider should follow local directions regarding spinal immobilization with the understanding that if no spinal involvement is likely, the patient may be better managed without immobilization. Penetrating neck injuries should be covered with an occlusive dressing if possible, to reduce the chances of an air embolism if bleeding is minimal. If ongoing bleeding is present, direct manual pressure can be used on one side of the neck. Obvious brisk bleeding from the neck may be best controlled with direct pressure above and below the bleeding site with the provider's two thumbs. Gauze under each thumb may assist with traction on the skin. If this is required to control significant bleeding, care should be taken not to change providers or stop the pressure to inspect the wound until arrival at the trauma center. Bilateral compression and circumferential dressings should be avoided because these may lead to cerebral hypoxia and infarction from bilateral carotid artery compression. Lastly, IV cannulation, if performed, is preferentially performed on the upper limb opposite the side of neck injury. Because the subclavian vessels may be involved, it is best to avoid infusing fluid that will travel through an injured vessel leading to clot disruption, greater exsanguination, and local hematoma formation.",
        "Penetrating head and facial trauma": "The prehospital approach and management of penetrating head trauma is similar to that for head injuries in general and is discussed in Volume 1, Chapter 30. However, the airway management of facial trauma deserves special consideration. Facial wounds that are otherwise survivable may lead to death due to airway compromise. Penetrating wounds or impaled objects may lead to significantly distorted airway anatomy and blood and foreign bodies in the airway. Any patient with penetrating facial injuries should be carefully considered for airway control. In addition to oral airway and oral endotracheal intubation, surgical airways, such as cricothyrotomy, may be required. Nasal airways should be avoided in patients with significant facial trauma.",
        "Prevention and public health issues": "There are approximately 7.2 million registered firearms in Canada, and 223 million registered firearms in the United States. US statistics indicate that approximately 40% of households have access to firearms. EMS personnel face a high probability of responding to locations where firearms may be readily accessible to the occupants. This presents both a challenge and an opportunity. The challenge is that EMS providers must be aware of their surroundings and ensure that the scene is safe to enter before beginning patient care. Emergency medical services providers also have an opportunity to recognize safety concerns in the home that are not seen by traditional hospital-based health care providers. An example of this would be a home where children are present and a firearm is seen within easy reach of the children. Although it may or may not be appropriate to educate the parents about the dangers of this circumstance at the time, it is an observation that can be relayed to hospital personnel or to the relevant child protection agency. Where children are felt to be at imminent risk, EMS providers may have a legal obligation to report this to the child protection agency (as do other health care providers).",
        "Medicolegal issues": "Most jurisdictions require reporting of certain types of injuries. Many require hospitals to notify the police of all patients who present to the ED with gunshot wounds. The role of EMS will vary between jurisdictions. Providers should be familiar with the specific legislation in their jurisdiction and what (if any) requirements exist for reporting gunshot or stab wounds. Emergency medical services providers should carefully document historical or physical findings. Patient care records are legal documents and can be used as evidence in a court of law. Unless a criminal act is witnessed, EMS providers should document what is seen and heard as opposed to what they are told or what they perceive may have happened. Examples of this include: \u201cThe patient states he was shot by his father\u201d rather than \u201cThe patient was shot by his father.\u201d EMS providers should not make suppositions about which wound is the entrance versus exit, but simply document the locations and descriptions of the two penetrating wounds.",
        "Penetrating extremity trauma": "Penetrating injury to the extremity can disrupt blood vessels, bones, nerves, muscles, and other soft tissues. This section will focus primarily on vascular and bony injuries. Vascular injuries are either higher pressure arterial injuries or low-pressure venous injuries, both of which can bleed profusely. Arterial injuries tend to be more serious and should be identified and acted on promptly to prevent further morbidity or mortality. Arterial bleeding is often a brighter red and spurts with each heartbeat. Venous bleeding tends to be darker and tends to flow as opposed to spurt. The majority of active bleeds, including arterial bleeding, can be managed with direct pressure. When these strategies fail, the application of a tourniquet can be considered. Details on indication and use of tourniquets and other modalities may be found in Volume 1, Chapter 35. Penetrating trauma can also cause bony injuries such as fractures or dislocations. These injuries should be considered open injuries because the penetrating object pathway will have exposed the injury to the outside. They should be treated as other fractures or dislocations by immobilization in the position found and dressing open wounds.",
        "Forensic issues": "Emergency medical services often responds to crime scenes or to patients who are the victims or perpetrators of crime. As such, providers need some understanding of forensics and evidence preservation. Wherever possible, the provider should ensure that neither the scene nor evidence is disturbed. \u2022 When a crime is suspected, notify the police immediately. When the police are already on scene, follow the instructions of the officer in charge, especially with respect to scene security and safety. When there is disagreement between law enforcement and EMS, the EMS provider should notify the appropriate supervisor and document all discussions. \u2022 When arriving on scene, ambulances should be parked to allow safe and rapid access to the patient, where possible without being on the immediate crime scene. \u2022 Gloves should be worn at all times. \u2022 Use the minimum number of providers needed. \u2022 Use the same route to get to and from the patient; avoid walking through fluids and other debris. \u2022 Try not to disturb physical evidence \u2022 Do not move or touch anything unless necessary to do so for patient care. \u2022 When it is necessary to move something, document it and notify law enforcement officials. \u2022 Do not cut through or near holes in patient clothing; they may be bullet or knife holes. \u2022 Any removed clothing and any personal articles should be left in the possession of law enforcement.",
        "Prehospital termination of resuscitation in penetrating trauma": "Up to one-third of all traumatic deaths occur before arrival at hospital, and prehospital traumatic cardiopulmonary arrest is associated with very poor survival (0\u20135%). Of patients who sustain traumatic cardiopulmonary arrest, isolated penetrating trauma (stab wound) to the thorax is the most salvageable subset of patients and any signs of life at the time of EMS arrival may reflect a potential survivor if transport time to a trauma center capable of ED thoracotomy is less than 15 minutes. In these very specific circumstances, ED thoracotomy may have up to a 25% survival rate. The higher survival is seen in those patients who did not arrest until after arrival in the ED, but there have been a few survivors where the arrest occurred up to 15 minutes before arrival. Thus, this group of patients requires the most rapid transport with no delay on-scene for additional procedures.\n\n\u201cFutility\u201d of prehospital medical resuscitation has been defined as less than a 1% chance of survival to hospital discharge and this is used to determine guidelines for ceasing resuscitation for non-traumatic cardiac arrest. Using the literature, and a similar definition for \u201cfutility,\u201d NAEMSP and ACS-COT prepared a joint guideline for termination of resuscitation in prehospital traumatic cardiopulmonary arrest."
    },
    {
        "Introduction": "An estimated 1.7 million people sustain traumatic brain injuries (TBI) annually in the United States, with total costs estimated at $60 billion per year. Overall, TBI-related deaths account for one-third of all trauma-related deaths, or 53,000 deaths annually in the United States. Traumatic brain injuries result primarily from falls (35%), motor vehicle collisions (17%), and direct blows to the head (16%). Men are more likely to sustain TBI than women for virtually all age groups. Children aged 0\u201314 account for approximately one-third of the cases of TBI. Children (up to age 18) and adults over 75 years old are more likely to present to the ED, and are more likely to die from head injuries. The initial brain insult occurs from direct impact, acceleration/deceleration injury, or penetrating wound resulting in bleeding, contusion, and ultimately cell death. Prevention measures include use of helmets, seat belts, car seats for children, and efforts to reduce falls in the elderly. Once the primary brain injury has occurred, reversal of the insult is impossible. Prevention of secondary brain injury is the goal of therapeutic intervention. Treatment must start with initial management on scene, and continue until the eventual resolution of the patient\u2019s injuries. Aggressive treatment of severe head injury patients has been shown to be cost-effective, with an increase in quality-adjusted life-years when all costs are considered. A review of a few physiological concepts is necessary for health care providers to understand how to prevent secondary brain injury. Cerebral perfusion pressure (CPP) is equal to the mean arterial pressure (MAP) minus the intracranial pressure (ICP). Measuring an accurate MAP in the prehospital setting may be difficult, making the systolic blood pressure (SBP) a surrogate that has been used in published guidelines and research. Rapid rises in ICP cause compression of the brain within an enclosed space (skull). As the pressure increases, the brain can be pushed downward, herniating in several possible directions. This herniation can cause compression of cranial nerves, posturing, changes in respiration, paralysis, and sudden death. Management of severe traumatic brain injury is focused on transport to a trauma center while preventing secondary brain injury. Secondary brain injury occurs through a complex biological cascade, which can continue for hours to days. Both hypotension and hypoxia are independently associated with increased mortality and poorer neurological outcomes. When hypotension and hypoxia occur together, a 75% mortality rate has been reported.",
        "Primary assessment": "The initial management of all injured patients should begin with airway, breathing, and circulation. Adequate oxygenation must be considered a critical priority in brain-injured patients. Hypoxemia occurs more frequently in brain-injured patients than is clinically suspected or recognized. Even a single episode of hypoxemia (SaO\u2082 <90%) can add to the overall morbidity, and has been associated with a 150% increase in mortality. Supplemental oxygen should be administered to all potential TBI patients with continuous monitoring of the oxygen saturation using pulse oximetry. Adequate circulation is also important in the head-injured patient. Just a single episode of hypotension, defined as a systolic blood pressure less than 90 mmHg, is associated with increased morbidity, and with a 150% increase in mortality. Intravenous fluids should be administered to maintain a systolic blood pressure of at least 90 mmHg. The optimal fluid choice for volume restoration and maintenance of blood pressure has been intensely debated. Isotonic crystalloid is recommended in both adults and children. Alterations in mental status due to hypoglycemia can easily be mistaken for those related to a traumatic brain injury. Patients with altered mental status should have a fingerstick glucose checked in the prehospital setting.",
        "Secondary assessment": "Performing an efficient neurological assessment is essential in the triage and management of brain-injured patients. Providers will need to repeat and reassess a patient\u2019s neurological status as it frequently changes rapidly. The Glasgow Coma Scale (GCS) was first introduced in 1974 by Teasdale and Jennett as a way to quickly evaluate the neurological status of brain-injured patients. The GCS has been widely adopted as a way to categorize head injury severity. The GCS should not be used as a static number and prehospital providers must frequently reevaluate neurological status, assessing for improvement or deterioration. A decrease of two or more points suggests increased ICP related to a potentially enlarging mass lesion (hematoma). A recent National Trauma Data Bank study of 250,000 head-injured patients found that 9% experienced prehospital neurological deterioration, defined as a decrease in two or more points in GCS from EMS to the emergency department measurement. This patient subgroup had higher in-hospital mortality even after adjusting for type of injury and presence of intracranial hemorrhage. Patients with measurable decline in mental status are high risk, and their initial care and evaluation should reflect the seriousness of this clinical finding. The GCS has been criticized for insufficient interrater reliability, especially in the outpatient setting. Recent studies have demonstrated that use of a Simplified Motor Scale (SMS) can be as predictive in outcome when compared to the traditional GCS in head-injured patients in both inpatient and out-of-hospital settings. The SMS scale gives only one score: 2 = obeys commands, 1 = localizes to pain, 0 = withdraws to pain or worse. The SMS has not been widely adopted but data are promising that SMS represents an alternative to traditional GCS, especially in the out-of-hospital setting. Current Brain Trauma Foundation guidelines are to continue using the GCS in the prehospital setting for now. The pupils must be evaluated for equality and reactivity to light. Asymmetry is defined as greater than 1 mm difference in diameter, and a fixed pupil is defined as less than 1 mm response to bright light. Unilateral pupillary dilation with decreased reactivity is a sign of increased ICP with uncal herniation causing compression of the ipsilateral third cranial nerve. The eye and orbit should be assessed for signs of direct trauma as unilateral pupillary dilation may be a normal variant. Bilateral pupillary dilation is more likely to be due to a metabolic or toxic cause and, if it is due to trauma, is a poor predictor with mortality reported at 60%.",
        "Other assessment considerations": "Alcohol use results in higher rates of traumatic injury, including head injuries. Intoxicated patients may be agitated or excessively sedated, making initial evaluation difficult. Blood alcohol concentrations above 80 mg/dL have been shown to have a linear effect on GCS. Safety precautions may prompt the use of sedatives such as benzodiazepines, opioids, and antipsychotics. It is preferable to overtriage potentially intoxicated patients to higher levels of care and assume that their changes in consciousness are related to brain injury and not intoxicants alone. Only with time and serial examinations can alterations in mentation be ascribed solely to alcohol or drugs. Anticoagulant and antiplatelet therapies are commonly used for a variety of medical conditions. Medications that affect platelet function (aspirin), platelet aggregation (clopidogrel), coagulation (warfarin), and thrombin (dabigatran) increase the risk of intracranial hemorrhage after trauma. EMS providers should inquire about the use of \u201cblood thinners\u201d and these patients should be treated with a high degree of concern for intracranial bleeding even in cases of mild head injury. Penetrating head injuries can be from missiles or impaled objects. Impaled objects should be left in place during transport as these objects will likely need to be removed in a surgical setting. Firearms are the leading cause of TBI death (40%) in the US, with an estimated 68% self-inflicted. The prognosis for penetrating head injuries is quite variable. Approximately two-thirds of patients die prior to hospital arrival. Poor prognostic indicators for the one-third who arrive alive to the hospital include a GCS of 3\u20135 on arrival, hypotension, bilateral hemisphere involvement, and bilaterally non-reactive pupils.",
        "Prehospital intubation": "Endotracheal intubation helps prevent both hypoxia and aspiration in severely head-injured patients. The controversy regards when the intubation should occur and by whom. A randomized trial of bag-valve-mask ventilation versus intubation in all children requiring prehospital airway management in Los Angeles County showed no difference in survival or neurological outcomes. When looking specifically at head-injured children, there again was no difference in outcome. This remains the best clinical study to date; however, it was performed in children in an urban EMS system, making generalizability to adult or non-urban settings questionable. Investigators in San Diego have published multiple studies on intubation in head-injured patients, showing consistently poor outcomes attributed at least partially to the adverse effects of inadvertent hyperventilation. They also question whether paramedic inexperience may lead to poor outcomes as they report an average of 0.5 intubations per paramedic annually. A randomized trial from Australia restricting intubation with end-tidal carbon dioxide monitoring to highly trained prehospital specialists when transport times were over 10 minutes reported a 97% intubation success rate, with no differences in the primary study outcome of extended Glasgow Outcome Scale at 6 months, but improved neurological outcomes at 6 months and no increase in mortality. Previously, hyperventilation was recommended for severely head-injured patients after intubation to decrease intracranial pressure. While hyperventilation does decrease intracranial pressure, it also decreases cerebral blood flow due to cerebral vasoconstriction, leading to decreased oxygenation of the brain. Currently, mild hyperventilation is indicated for brief periods to treat suspected cerebral herniation. Signs of cerebral herniation include dilated and unreactive pupils, asymmetric pupils, a motor exam that identifies either extensor posturing or no response, or decrease in GCS score by 2 points or more. Hyperventilation goal should be end-tidal CO\u2082 of 30\u201335 mmHg, monitored with capnography and used only as a temporizing measure. An end-tidal carbon dioxide of 35\u201340 mmHg is recommended for intubated head-injured patients. Unfortunately, inadvertent hyperventilation occurs in as many as 70% of cases, perhaps due to unintentional provider actions or confusion over prior hyperventilation recommendations. Continuous end-tidal capnography is recommended and has been shown to reduce hyperventilation. A Cochrane review article from 2008 suggests that there is no evidence for prehospital intubation in urban, ground transport systems. The Brain Trauma Foundation recommends that EMS systems develop specific protocols that include monitoring of oxygen saturation, blood pressure, and when possible end-tidal carbon dioxide prior to EMS intubations. Prehospital intubation use must be clarified at a local level in the context of transportation distance and time along with local infrastructure and geographical factors.",
        "Additional Treatment": "Mannitol is widely used in the hospital setting to reduce intracranial pressure, which may reduce relative risk of death. There is currently insufficient evidence to recommend the use of mannitol in the prehospital setting.\n\nIn a recent randomized study, prehospital use of hypertonic saline following severe TBI showed no improved outcomes at 6 months, nor change in survival in patients who were not in shock. Normal saline for volume resuscitation to maintain adequate blood pressure, defined as SBP of greater than 90, is currently recommended. The most recent Brain Trauma Foundation guidelines recommend hypertonic fluid resuscitation as an \u201coption\u201d for patients with GCS <8.\n\nThe administration of albumin has been shown to worsen outcome in patients with TBI, therefore its use is not recommended. Steroids have been shown to increase the risk of death and are no longer recommended in head-injured patients and are no longer widely used. Seizures resulting from brain injury place excessive metabolic strain on an already injured brain and should be treated quickly to prevent further hypoxic insult. The risk of post-head injury seizures is noted to be higher in children. There is no evidence to treat head-injured patients prophylactically for seizures in the prehospital setting.\n\nThe adoption of therapeutic hypothermia in the context of post-cardiac arrest care has led to research into the use of therapeutic hypothermia in severely brain-injured patients. To date, the effectiveness of therapeutic hypothermia for head injury has largely been inconclusive. Some have argued that hypothermia treatment has not been initiated early enough in prior trials, and that a difference in outcome may be noticeable if cooling is started closer in time to the injury. Currently, there are no randomized controlled studies to support the use of prehospital therapeutic hypothermia in brain-injured patients.",
        "Sports-related head injuries": "Sports-related head injuries occur frequently, estimated at 3.8 million sports-related concussions annually in the US, with the most common sports being football, hockey, rugby, soccer, and basketball. EMS personnel often provide care at youth athletic events and are the first to evaluate these athletes after injury. All athletes with suspected head injuries should be removed from activities and be evaluated by a medical professional. Athletes who sustain head injuries should not return to play that day. Patients with symptoms such as altered mental status, continued vomiting, retrograde amnesia, and loss of consciousness should be transferred to an emergency department. ",
        "Pediatrics Glasgow Coma Scale": "Prehospital concepts for pediatric traumatic brain injury are similar to those in adults; however, there are some important physiological differences. Children are more susceptible to TBI because of their large heads, thinner bones, and developing brains. Pediatric patients are more prone to brain edema, with more diffuse axonal injuries than primary bleeding or brain contusions. The classic Cushing reflex (hypertension, bradycardia, and respiratory irregularity) is more commonly seen in children. Skull fractures have a significantly higher rate of having intracranial pathology compared to adults, along with a much higher rate of seizures. Non-accidental trauma must also be considered in pediatric head injuries, especially with injury patterns that do not match the history given by caregivers, or if there are other concerning injuries such as multiple bruises or old, unexplained fractures are found on exam or imaging. Therapeutic cooling trials have had some positive studies to date in children; however, currently there is not enough evidence to recommend that cooling be initiated in the prehospital setting in children.",
        "Prevention": "The frequency and severity of TBI can be reduced through preventive efforts. Prehospital personnel can identify potential hazards or risk-taking behaviors as they are usually the only health care providers who actually enter a patient's living environment or witness the scene of a traumatic event. This allows the provider to either directly educate the patient and family or relate appropriate observations to ED staff when the patient is transported to the hospital. Examples of preventive environmental modifications to reduce the potential for head injury include window guards and safety gates at staircases to prevent children from falling. Falls in the elderly can be reduced by removing loose rugs and encouraging exercise program participation to maintain or improve muscle strength. Firearms in the home should be kept unloaded in a secure, locked container or cabinet with ammunition stored in a different location. Appropriate protective equipment including a helmet should be worn whenever riding any wheeled device or when engaging in contact sports such as hockey, football, boxing, baseball or softball, riding a horse, skiing, or snowboarding. Seat belts should always be used by adults and appropriately sized child safety and booster seats should always be used by children riding in vehicles.",
        "Transportation and destination decisions": "Destination decision making can significantly alter the outcome of a patient with TBI. When an organized trauma system is in place and patients are taken directly to an appropriate facility, survival from TBI improves. Patients in the moderate or severe TBI group (GCS 13 or less) should be directly transported to a trauma center that is fully equipped and staffed to manage acute neurosurgical emergencies. Patients classified as mild TBI (GCS 14 or 15) can generally be transported to other facilities based on established destination protocols, assuming the patient's other injuries do not require care at a trauma center. A retrospective evaluation of trauma databases suggested that transporting elderly TBI patients (>70 years) with a GCS of 14 directly to a trauma center may reduce this group's higher morbidity and mortality. Transport mode (air versus ground) should consider local factors including but not limited to traffic, weather, available transport vehicles, and provider availability to minimize overall prehospital time.",
        "Conclusion": "Traumatic brain injury remains a common cause of disability and death. Injury prevention through public health initiatives such as the use of seat belts and helmets is the mainstay of primary brain injury prevention, with the major goal of treatment being to prevent secondary brain injury. Secondary brain injury is caused by hypoxia and hypotension. Preventing hypotension and hypoxia are the goals of prehospital care. Prehospital intubations, when performed, should be undertaken by experienced providers with the use of continuous end-tidal monitoring, especially in cases of severe injury with long transfer times. Once intubated, providers should avoid hyperventilation. The mental status of head-injured patients should be continually reassessed as those who have a precipitous deterioration in mental status have increased morbidity and mortality. There is not enough consensus to recommend prehospital cooling, hypertonic saline, or prehospital administration of mannitol in severe head injury patients."
    },
    {
        "Introduction": "In its broadest sense, a trauma system consists of both an organized approach to managing patients who have suffered acute injury, across the continuum from initial medical care through rehabilitation, as well as injury prevention activities aimed at those at risk of suffering trauma. While the trauma system should be integrated with both public health and emergency management, there is significant overlap between trauma and EMS systems. This chapter will focus primarily on the close interaction between these two systems.",
        "Trauma system organization": "Trauma systems are typically organized on a state-wide basis, although some larger counties may have sophisticated systems. In 1988, West and colleagues described the ideal criteria for a state-wide trauma care system. State laws generally delegate the authority for designation of trauma centers to a state agency, such as a department of health, and describe the process by which hospitals may seek designation. Because of their close relationship, most state trauma offices are colocated with the state office of EMS. While most states utilize the standards promulgated by the American College of Surgeons Committee on Trauma (ACS-COT), some states opt to draft their own trauma center criteria. The term \u201cdesignation\u201d refers to authorization from a state agency for an institution to represent itself to the public as a trauma center, while \u201cverification\u201d refers to the inspection by a non-biased team of experts (usually from outside the community) who have confirmed that all necessary services and processes are in place to meet the ACS-COT (or equivalent) standards. In the ideal trauma system, the lead agency would have the authority to designate trauma centers based upon need, rather than simply approving any facility that desires designation in a competitive, free-market approach. Need for additional trauma centers should be based upon the population of a geographic area, the volume of trauma patients encountered, or proximity to other designated centers. Trauma centers that regularly see large numbers of patients are able to maintain readiness so that management becomes a matter of routine practice, while those that fail to see sufficient numbers of injured patients, especially the seriously injured, may find that their personnel struggle to maintain their organizational processes and procedural skills. Like the trauma centers themselves, performance improvement is a key component of a trauma system. Data collected in trauma registries are pooled on a system-wide basis and analyzed. This information may provide insight for focusing injury prevention activities in addition to opportunities for improvement in system design or the need for education. Over the past few years, the ACS-COT has developed the Trauma Quality Improvement Project (TQIP) which conducts risk-adjusted analysis of outcomes at trauma centers that voluntarily participate. By presenting its data as observed-to-expected ratios, TQIP allows centers to voluntarily benchmark themselves to other centers across the country. When fully implemented, TQIP will allow high-performing trauma centers (low observed-to-expected ratios) to share best practices with lower performing facilities (high observed-to-expected ratios). Most states have trauma advisory committees composed of individuals who represent stakeholder sectors involved in trauma care in that state. These committees provide oversight and advise the state trauma office on matters related to improvements in their trauma system. These committees often draft or approve a state trauma plan that serves as a strategic blueprint for enhancing the system over a period of time. Often the state trauma advisory committee also assists the state in determining how governmental funding, if available, will be distributed to stakeholders in the trauma system. This funding helps offset the expensive costs of maintaining trauma center readiness and data collection for trauma registries and aids with the uncompensated care delivered by these centers. State funding may also help provide education to individuals who care for trauma patients and may even purchase some needed equipment.",
        "Trauma care facilities": "Trauma centers represent one of the essential components of a trauma system. A trauma center is an institution committed to the care of injured patients across the spectrum of initial resuscitation through rehabilitation, including operative management and critical care. A trauma center is a unique blend of personnel (surgeons and other physician specialists, nurses, and allied health care workers), equipment, and processes (robust ongoing performance improvement program). The various physicians, nurses, therapists, and technologists must work together as a cohesive team, under the direction of the trauma surgeon. The most widely accepted criteria for trauma center designation are those promulgated by the ACS-COT. - Level III trauma center: the \u201cbasic\u201d trauma care facility that possesses a 24-hour emergency department staffed by emergency physicians. General surgeons must be immediately available while orthopedic surgeons, plastic surgeons, radiologists, and anesthesia personnel must be on call. - Level II trauma center: capable of managing more complex cases. Trauma surgeons must be available within 15 minutes of the arrival of the most critically injured patients. In addition to the criteria from Level III, a Level II center must include on-call physicians in the following specialties: neurosurgery, hand surgery, obstetrics/gynecology, ophthalmology, oral/maxillofacial surgery, thoracic surgery, and critical care medicine. - Level I trauma center: the highest level trauma center. While medical capabilities are only slightly enhanced over the Level II facility (cardiac surgery with cardiopulmonary bypass capability and microvascular capability for replantation), a Level I center must have operating room personnel who are in-house around the clock as well as a surgically directed critical care service. In addition to providing the most comprehensive trauma care, a Level I facility serves as a regional referral resource. As part of its teaching responsibilities, a Level I center must participate in training of surgical residents and conduct Advanced Trauma Life Support courses. Level I facilities must also have an ongoing research program related to injury. When first conceived, the system that included only Level I-III facilities was seen as an exclusive system, allowing only hospitals with certain minimal capabilities to participate. In response to this criticism, the ACS-COT added the Level IV trauma facility, which is a smaller hospital with limited capabilities that is viewed as a resuscitation point in a community that lacks Level I\u2013II trauma centers. Following attempts at initial stabilization at a Level IV center, the injured patient would be transferred on to a higher level of care in a more distant location. The Level IV centers allowed for the creation of an inclusive trauma system and the ability to provide full geographic coverage for a regional system. In additional to trauma centers, other facilities included in the trauma system are specialty hospitals, such as pediatric trauma centers or spinal cord injury facilities, and rehabilitation hospitals. In some communities, patients with isolated spinal cord injuries may be transported directly to an institution dedicated to managing spinal trauma and rehabilitation.",
        "Communications": "Communications are a key aspect of both the EMS and trauma systems. Traditional telephone (landline) and cellular phones are used by callers to access public safety answering points via 9-1-1 in order to report trauma victims. After obtaining essential information for EMS response, trained emergency medical dispatchers are capable of providing prearrival instructions of Basic Life Support measures that a lay bystander could provide while EMS is responding, such as direct pressure for hemorrhage control. Dispatchers also gather additional information from callers or first responders about the need for specialized personnel or equipment, such as extrication or hazardous materials experts. For the most critically injured patients, rapid response and transport should result in a more expeditious arrival of the patient at the trauma center. Radio communications are used both between the dispatch center and the responding/transporting EMS unit, as well as between the EMS unit and the receiving facility. Prompt notification of the trauma center that a seriously injured patient is en route allows the facility to assemble its trauma team in the emergency department prior to patient arrival. Some recent mass casualty events, such as the terrorist attacks of 11 September 2001, illustrated that many public safety agencies (law enforcement, fire, and EMS) were unable to communicate with each other. Since then, emergency management organizations have focused significant emphasis on increasing interoperability, resulting in enhanced communication between first responders in an effort to improve mass casualty response. Many state trauma and EMS agencies host a website for receiving facilities to post their current status (open versus on diversion, etc.). Some of these web-based systems are robust enough to indicate the number of available beds, permitting a rapid assessment of surge capacity in a disaster.",
        "Emergency response": "The greatest overlap between the trauma and EMS systems is seen with emergency response, from dispatch of EMS to patient arrival at the receiving facility. The adage of \u201cgetting the right patient to the right place in the right amount of time truly describes the challenge faced by EMS providers when caring for trauma patients. \u201cField triage\u201d represents the decision making for selecting which injured patients (\u201cthe right patient\u201d) require transport to a trauma center (\u201cthe right place\u201d). In 2006 and again in 2011, the Centers for Disease Control and Prevention assembled national expert panels to review evidence and revise the field triage algorithm originally developed by the ACS-COT. The right amount of time\u201d includes decisions regarding both the interventions and time spent at the scene as well as determining the best mode of transport, namely ground EMS versus air medical service. While air medical transport can get an injured patient from a distant scene to a trauma center significantly faster than ground transport, ground transportation may be more expeditious when the patient is located closer to the trauma center (within 10 miles or so), because of the time required to set up a landing zone and power up and power down engines. Trauma surgeons should have input into regional protocols regarding transport modality of injured patients. Emergency medical services personnel may also be called upon to transport a patient from initial receiving facility (perhaps a non-trauma center) to a trauma center. The care required en route (Basic Life Support versus Advanced Life Support) and need for rapid transfer are the major determinants of whether ground or air transport is utilized. In some jurisdictions, the transferring facility may need to send a nurse along with the patient if the patient requires care that exceeds the scope of practice of the EMS personnel (e.g. in many jurisdictions, an EMS provider may not transfuse blood unless also licensed as a nurse). All ACS-COT verified trauma centers are required to participate in public and professional education. Several standardized trauma training courses for EMS personnel exist, including Prehospital Trauma Life Support (PHTLS) and International Trauma Life Support (ITLS). Many EMS systems require their personnel to maintain current certification in one of these programs. These courses provide an opportunity for nurses and physicians from trauma centers to share their expertise in managing trauma patients. Some trauma centers provide regularly scheduled case reviews for EMS personnel, offering follow-up on diagnostic procedures and management after arrival at the facility, in combination with reinforcement of basic trauma care principles.",
        "Medical oversight": "Medical oversight for EMS is divided into direct and indirect oversight. Direct oversight involves providing instructions to prehospital care providers via radio or telephone. In the early days of Advanced Life Support in the prehospital setting, this form of medical direction was heavily utilized with the thought that close communication between the receiving or base station physician and the EMS providers was essential for quality care in the field. Because of the time involved in contacting a physician, direct medical oversight may actually be associated with longer prehospital times. As years passed, focus has shifted more toward one form of indirect medical oversight, where EMS providers follow written protocols or treatment guidelines, each focused on a specific condition or chief complaint. Given the staffing of receiving emergency departments, direct oversight is virtually always provided by emergency physicians rather than trauma surgeons. Another aspect of direct medical oversight involves a physician riding along with EMS personnel to monitor care and providing orders in those circumstances. Unlike emergency physicians who have mandatory rotations in EMS during their residencies, most trauma surgeons have limited exposure to prehospital care, unless they worked as EMS providers before medical school. As a result, trauma surgeons often have a poor understanding of how prehospital care is delivered and the unusual circumstances under which EMS providers must render care. One could argue that it would be beneficial for trauma surgeons to occasionally spend some time in the field observing the assessment and management delivered by both ground and air EMS personnel. There are significant opportunities for trauma surgeons to participate in indirect medical oversight. In fact, trauma surgeons should have the opportunity to actively participate in the development of, or review and provide input to, written protocols utilized by the EMS providers in their trauma system. As a part of their performance improvement program, trauma centers should review the prehospital care provided to patients transported to their facilities. Most commonly, this is accomplished by review of the patient care reports for the most critical patients or those who died in the emergency department. Feedback should be provided to the transporting EMS agency, either through its performance improvement coordinator or the service medical director. Similarly, some trauma programs invite representatives from EMS services to participate in their monthly performance improvement meetings.",
        "Data collection": "Data collection is an essential component of the trauma system, and the data are utilized in many ways. All trauma centers are required to maintain trauma registries, databanks of key information regarding the trauma patients managed at their facilities. Data from these institutional trauma centers are then pooled on a system level, either regional or statewide. Many centers also voluntarily submit data to the National Trauma Data Bank (NTDB). In some trauma systems, all hospitals, including those that are not trauma centers, are required to provide information about the injured patients for which they care, as not all injured patients require management at trauma centers. This allows the system to evaluate undertriage of trauma patients, which occurs when patients requiring trauma center capabilities are transported to hospitals that are not trauma centers. The ACS-COT believes a highly functioning trauma system has an undertriage rate of 5% or lower. Data are the basis of a strong performance improvement project. By collecting data on complications or other issues, a trauma center or system may identify a problem that should be addressed. Such trends pose an opportunity for implementing a process change that is anticipated to result in improved care. In fact, progressive trauma systems have adopted a public health model that consists of three core phases: assessment, policy development, and assurance. In the trauma system, the assessment phase consists of data collection followed by data analysis. Once problems are identified, solutions are proposed and implemented in the policy development phase. Finally, in the assurance phase additional data are collected to confirm that the implemented intervention is producing the desired effect, e.g. lowering complications, etc. These three phases create a never-ending loop of performance improvement wherein the trauma center or system continually strives to provide better and better care. Research is another important use of the trauma registry. As these registries include increasing numbers of patients, they provide a rich repository of data for retrospective studies comparing different management options and their respective outcomes. Linkages between databases of EMS records to hospital or system trauma registries allow for analysis of the relationship between the EMS system and trauma system. Efforts are currently under way to link the National EMS Information System to the NTDB. This linkage will permit robust analysis of how prehospital interventions and system design affect the outcome of trauma patients.",
        "Emergency management": "Emergency management is the discipline that focuses on the care of citizens affected by various disasters. Because there is significant overlap between the issues that arise from many different types of disasters, modern emergency management systems tend to utilize an all-hazards approach rather than developing different responses depending upon the type of the disaster. Because most disasters include some number of injured patients, there needs to be close cooperation and interaction between emergency management and trauma programs, both inside the trauma center as well as on the system level. Trauma centers should have internal strategies that open up extra beds, thereby creating surge capacity in the event of a disaster. Preplanning is essential for successful disaster response. Along with their colleagues in emergency management, leaders in the trauma program should periodically test their trauma center's readiness by conducting disaster drills. Ideally, drills should be held on different days and shifts to ensure all members are properly prepared. Similarly, trauma systems and their corresponding emergency management agencies should evaluate their system's preparedness through drills that include numerous simulated patients, multiple EMS and first responder agencies, regional emergency management personnel, and multiple facilities. Such drills can uncover potential system weaknesses while emphasizing the need for system coordination and communication.",
        "Injury prevention": "Injury prevention represents another aspect of the integration between the public health model and the trauma system. In this model, trauma is viewed as a disease and efforts should be focused on preventing new cases. Trauma registry data, either from the trauma center or the trauma system, are analyzed to determine common causes of injury (e.g. motor vehicle crashes or falls) and at-risk groups (children or the elderly). Interventions aimed at preventing or ameliorating these injuries are conceived and implemented. Further analysis is used to monitor for the effect of these prevention strategies. In some EMS systems, EMS professionals routinely participate in injury prevention activities, such as distribution of car seats and educating parents on their use, or providing evaluations of homes for the elderly looking for conditions that may lead to falls, such as throw rugs or lack of anti-slip mats in bathtubs.",
        "Conclusion": "Trauma remains the leading cause of death for individuals between the age of 1 and 44 years. Significant overlap exists between the trauma and EMS systems, community public health, and emergency management. Although these systems each have somewhat different objectives, when these systems coordinate their activities related to injury and the injured patient, great strides can be accomplished toward achieving optimal care of the injured patients on a regional basis."
    },
    {
        "Introduction": "Trauma is a very common EMS response. According to the National Emergency Medical Services Information System (NEMSIS) database, injuries accounted for 14.6% of EMS calls in 2012. Despite advances in the management of injuries over the last several decades, trauma remains the most frequent cause of death for Americans aged 1\u201344 and the fifth largest overall cause of death nationwide. Nearly 120,000 Americans died from unintentional injuries in 2010. Improvements in trauma care require research. Many of our beliefs and practices over the years have changed as a result of research that has challenged conventional medical wisdom. There are many examples of trauma therapies that were previously used but later were no longer considered to be the standard of care following research. These include pneumatic antishock garments, aggressive fluid resuscitation, and certain forms of airway management. Our recent wars in Iraq and Afghanistan have provided a new venue for observational trauma research that has yielded valuable insights. Of note, many of these trauma therapies can be used both in military and civilian trauma settings.",
        "Prehospital trauma study types": "There has been great interest in the last decade in providing evidence-based care in the EMS setting. This requires ongoing research efforts to establish a knowledge base that will support reliable conclusions regarding optimal EMS care and the development of valid and verifiable clinical treatment guidelines for providers. Similar to any clinical research, prehospital trauma studies can be of a variety of types. These include (in descending order of rigor): prospective randomized clinical trials (RCTs) (double-, single-, or unblinded), prospective/retrospective observational/cohort trials, retrospective reviews/database analysis/case\u2013control studies, case series/case reports. The \u201cgold standard\u201d in clinical research has been the prospective randomized double-blind clinical trial. In this type of study, patients are randomly assigned to one treatment arm or another and the outcomes of each treatment group are analyzed. If the clinical trial is designed so that the only difference between the two arms is the treatment modality being randomized, it makes it possible to know if the therapy provides patient benefit. The \u201cblinding\u201d ensures that the patient, the researchers, or both do not know into which group each patient is assigned. This blinding minimizes bias that could change other ways in which the patients in the two study groups are treated. Randomized and blinded trauma clinical trials are difficult to conduct in the EMS setting because the consent and randomization procedures in this emergency situation are often not feasible. One early example of a prehospital trauma RCT is the 1994 study by Bickell et al. looking at the effects of the administration of IV fluid in trauma patients. In this trial, hypotensive trauma patients who had sustained penetrating trauma were randomized on even days to receive standard infusions of IV fluid and on odd days to receive no IV fluids until mechanical control of hemorrhage was achieved in the operating room. In this study, consent to participate was \u201cimplied,\u201d therefore informed consent requirements were waived, greatly simplifying enrollment in this study. (This approach to consent is no longer permitted in the United States.) A more recent example of a prehospital RCT is the 2009 study by Moore et al. of human polymerized hemoglobin in the treatment of traumatic hemorrhagic shock patients in the EMS setting. This trial randomized patients to be resuscitated with either crystalloid or Polyheme, and was conducted using an exception to informed consent as per the federal regulation 21$CFR50.24. Cohort/observational studies provide clinical information despite the possibility of treatment and/or observational bias. In these studies, there is no \u201cactive\u201d treatment intervention being randomized and evaluated. Instead, one or more groups (cohorts) are defined and patient outcomes evaluated based on the use of specific treatments. It is important to note that cohort/observational studies can be either prospective or retrospective. In a prospective cohort study, the study parameters, patient cohorts, and outcomes are defined before each group undergoes the treatment. In a retrospective observational study, the information being studied has already been collected but the study questions and outcomes of interest have not been established. In order to minimize bias in these retrospective studies, the researchers must define the patient cohorts and study outcomes prior to analyzing the database. Retrospective studies, although more prone to bias than prospective studies, are often easier to conduct because the data already exist, for example in a state trauma registry. An example of cohort analysis in trauma is a study by Holcomb et al. In this multi-center study, several groups of trauma patients receiving various transfusions of blood products were followed and their outcomes analyzed. There are multiple databases available for analysis to EMS researchers. Because of the popularity of electronic patient care records, many EMS agencies now have databases available for research analysis of the patients to whom they have responded. Many states require hospitals to report to a state-wide trauma registry. In addition, many state EMS offices collect EMS data and provide a state-wide view of EMS activities. The NEMSIS database is a national compilation of EMS data, supplied by participating state EMS offices, and offers the broadest overview of EMS nationally. While these databases can be a very valuable resource for trauma research, great care must be taken in study design to ensure valid conclusions can be drawn from the data. Database analysis can be prone to bias if the study parameters are not strictly defined before analysis takes place. \u201cData mining\u201d is the analysis of a database for patterns prior to the formation of a hypothesis and strict study parameters. Although care must be taken to avoid unsupported conclusions, data mining can assist in developing hypotheses for future clinical trials if any observed differences in patient outcome are believed to be based on treatment differences. Case\u2013control studies compare two groups of patients whose outcomes differ. This research format is especially useful when the adverse outcome of interest is observed infrequently. The case group is matched to the control group only on a minimum number of variables, so that it is possible to examine which variables differ in the two patient outcome groups. These studies may quickly identify a characteristic or treatment that imparted the observed difference in patient outcomes between the cases and the controls. This format was used in the study by Shayne that examined the need for angiography in penetrating thigh trauma. Case reports often are the starting point for the analysis of a case series or the initiation of a case\u2013control study. The most important aspect of these reports is either the observation of a new disease or complication, or the potential benefit of a newly attempted therapy. Data gathering and analysis of EMS patient care are performed as part of the quality assurance (QA)/performance improvement (PI) process needed to improve patient outcomes. In this process, a new protocol, medication, procedure, or device is implemented by the EMS agency after review of current medical literature and approval by its medical director, training officer, and other senior administrative personnel. After training of the EMS providers, this change is implemented and the outcome of the intervention is monitored as part of the QA/PI process. There is no control group, although sometimes the outcome may be compared to that of \u201chistorical controls,\u201d a similar group of patients treated differently prior to the initiation of this new therapy. When studying the effects of a new therapy, it is often necessary to wait some period of time, after which it is likely that the new therapy being reviewed for quality has been fully integrated into the EMS system of care. This non-studied \u201cwash-out period\u201d helps to remove any inaccuracies that may influence the study outcome as a result of incomplete or inaccurate adoption of the treatment being studied as the system and providers become accustomed to it. This QA/PI process allows for the implementation of therapies with proven efficacy in the research setting. The subsequent QA/PI monitoring of patient outcomes allows EMS providers to compare current outcomes to those observed when other therapies were provided in order to establish that the new treatment approach enhances patient outcomes.",
        "Design issues in prehospital trauma studies - Patient informed consent": "Issues surrounding patient consent for participation in prehospital clinical trials are among the most difficult technical research issues to resolve. Federal law and investigational review board (IRB) policies regarding research on human subjects require that the patient provide informed consent before participating in a clinical trial in order to preserve the patient\u2019s autonomy. This typically involves the patient being counseled about the medical issue being studied, the different therapies that may be provided, and the potential risks and benefits of participating in the clinical trial. This consent process allows the patient to make an informed decision about whether or not to participate in the clinical trial being proposed. This issue is obviously problematic for emergency research in general, and especially in the prehospital setting, because the urgency of the patient\u2019s condition often makes obtaining consent from either the patient or a legally authorized representative unfeasible. Trauma victims often are unconscious, in severe pain, or have unstable vital signs, all of which can impair their ability to make an informed decision about participation in a clinical trial. Because the requirement for informed consent had the potential to prevent critical prehospital research from being performed successfully, the National Institutes of Health (NIH) and Food and Drug Administration (FDA) collaborated with clinicians interested in emergency research in establishing the rules that would allow for an exception to informed consent when it cannot feasibly be obtained. In federal regulation 21\u00a7CFR50.24, the United States government has allowed for an exception to informed consent in certain emergency and prehospital studies. Once a patient who has been enrolled in such a study is stabilized, the study involvement can then be explained to the patient or legally authorized representative. At this later time, the patient or representative has the option to withdraw from the study but still be cared for by the clinicians who are the designated care providers. In the study of a hemoglobin solution in the management of traumatic hemorrhagic shock patients, the exception to informed consent rules were used for the first time. Virtually all of the patients or family members agreed to continue participation in the trial. The use of an exception to informed consent can be simplified with the use of scripts, algorithms, and a plan that allows patients to \u201copt out\u201d of the study, even if they cannot provide informed consent to participate in the study.",
        "Inclusion and exclusion criteria": "Inclusion and exclusion criteria define the patient population being studied. The goal of these criteria is to establish a group of patients that is easily identified, clinically relevant, uniform in the expected outcome, and generalizable to patients treated in the clinical setting. In many trauma studies, the initial decision must establish whether or not to limit the study population to patients with either blunt or penetrating injuries. This decision reflects the potential outcome differences that are seen in these two patient groups. Blunt trauma patients may have a greater spectrum of injuries (traumatic brain injury, chest contusion, pelvic fracture, and hepatic laceration, for example), whereas penetrating trauma patients may have multiple wounds based on the path of the projectile. In addition, the distinction can become blurred when a patient sustains combined penetrating and blunt injuries, such as may result from a blast injury. There may be several advantages to including all trauma patients in an EMS clinical trial regardless of the mechanism of injury, including the speed of patient enrollment and the ability to apply the results to both patient subgroups. However, because outcomes differ in these two groups, this may interfere with the ability of the study to establish with certainty the effect of the intervention being studied. As a result, it is often prudent to conduct parallel clinical trials, one for patients with blunt trauma and the other for those with penetrating trauma. Another research consideration is how terms such as \u201ctraumatic hemorrhagic shock\u201d are defined. An analysis of the published literature will reveal standard definitions, such as hypotension being defined as a systolic BP <90mmHg. The exclusion of patients with blood pressures that are not measurable is an important consideration, as the outcomes of traumatic arrest patients may be so poor that the effects of the study intervention would not be possible. The best approach is to define a population of traumatic hemorrhagic shock patients who could improve with optimal care, including the study intervention, but that also includes patients whose outcomes could suffer without optimal care. This situation provides the \u201cclinical equipoise\u201d necessary to establish a compelling clinical question and the justification for the use of an exception to informed consent.\n\nAnother important definition is which patients are \u201cpediatric\u201d and which are \u201cgeriatric.\u201d Decisions regarding inclusion of children and the elderly in prehospital trauma research should be carefully considered. The differences in physiological responses to trauma in very young children and the elderly are well documented. To account for these differences, the Trauma Score-Injury Severity Score (TRISS) method for predicting outcome in trauma includes age as a factor in its calculation. It is common in prehospital trauma studies to include only patients whose ages fall in the 18\u201365 range. The disadvantage to this approach is that the research generates inadequate knowledge about the potential benefit of the study interventions to children and the elderly. In order to most accurately evaluate the benefit of clinically effective therapies in these special populations, clinical trials can be subsequently conducted where efficacy is determined in the <18 and >65 age groups. Researchers should consider excluding patients from clinical trials when injuries render them not likely to survive, regardless of treatment with the investigational therapy or standard therapy. Inclusion of these critically ill patients who have non-survivable injuries could bias the results towards showing no difference in outcome when one actually exists. Patients with these critical injuries include those with severe traumatic brain injury (Glasgow Coma Scale score less than 5), traumatic arrest with no recordable blood pressure, and other signs of likely demise.",
        "Randomization and blinding": "The ideal RCT incorporates rigorous randomization procedures to ensure that patients are not preferentially entered into one or the other treatment arm of the study. There are many techniques for randomization. One common technique is simple alternation of treatment based on the day of the week or even/odd dates. This method is simple and easily remembered by the EMS personnel performing the interventions. However, there is the possibility of a treatment bias by the medics in knowing ahead of time how a patient will be treated that day. A better technique is the opening of an envelope to reveal the treatment arm for a particular patient after the decision is made to enroll. Another method is to contact direct medical oversight or dispatch for random assignment of a treatment arm to a particular patient, eliminating possible bias by the treating personnel. Once randomization occurs, it is necessary to analyze the data using an \u201cintention to treat\u201d design, whereby all patients randomized to a therapy are analyzed as if they received that therapy, even if that therapy was not provided for some reason. This analysis method will allow for an adjustment in outcome that could occur due to bias in the delivery of the therapies in the clinical trial. The ideal RCT also involves blinding of the trial participants. In a double-blinded trial, neither the patient nor the treating health care providers, including the EMS crew, know which treatment the patient is receiving. In a single-blind study, either the patient or the provider does not know which treatment is being provided. It is sometimes easier to blind a medication by using an identical-looking placebo or active medication that is provided by the research team. For example, a nebulized medication could be provided that is prepackaged and visually identical in both treatment arms, but half of the randomization packages contain standard therapy (for example, albuterol) and the other half contain the study medication, either in place of or in addition to the albuterol. It is often difficult to blind the treatment being studied in trauma clinical trials if a procedure such as intubation is involved or if the use of a blood product is being studied.",
        "Selection of outcome measures": "The proper selection of outcome measures is another aspect of trauma clinical trials that is essential to understanding the efficacy of a therapy under study. A study that identifies an outcome that is not clinically relevant may not lead to a change in the standard of care. Outcomes of interest may be those that are either globally relevant, such as 30-day survival, or incrementally important, such as survival to the emergency department, operating room, or intensive care unit. Although survival is a simple and non-biased outcome measure, its use may not allow for the future use of therapies that provide less dramatic benefit, such as improved 24-hour survival. When mortality is used in trauma studies, the survival of a patient treatment group can be estimated using the TRISS method, and this estimated survival compared to the survival of the treatment group that receives the intervention or therapy under study. Another well-accepted and reproducible outcome measure, relevant to prehospital traumatic brain injury and stroke research, is the Cerebral Performance Category (CPC). This score has proven useful in measuring the outcomes of brain-injured patients. Other examples of common outcome measures in trauma clinical trials are endotracheal intubation and operative intervention rates, morbidity as measured by organ dysfunction scores, intensive care unit days, and total hospital days. In retrospective studies, the goal is often to describe the outcome of a current practice, so that future prospective research can clarify the effect of a change in this practice. For example, how much saline is normally administered in the EMS setting or the ED for trauma patients who present with traumatic hemorrhagic shock? This information regarding current standard practice could allow prospective trauma studies to be better designed so that new therapies can be identified and tested against the current standard. In an excellent discussion of clinical research study design, Hanson has the following recommendations regarding outcome measures. They should be directly tied to the specific aims and capable of measuring the outcomes of interest. They should be important to patients. Patient-reported outcomes should be considered.\n\nThe issue of outcome measures that are important to patients has become more prominent recently. They have been described as qualitative outcome measures or patient-reported outcome measures (PROMs). This process often involves the patient completing a questionnaire or survey after participation in a clinical trial to get his or her perspective on the outcome. These qualitative outcome measures can be combined with the more common quantitative measures in a study. This approach can help ensure maximum clinical and therapeutic relevance to study outcomes.",
        "Establishing the clinical therapy of standard care patients": "Another important aspect of clinical trials research is the establishment of how the care of those who are treated in the standard care group is provided. This is especially true if the providers are aware of which treatment group a patient has been assigned to. When there is not double-blinding, it is necessary to either establish how the standard therapy group is treated (e.g. infuse 3 L of normal saline for all patients whose initial SBP is <90 mmHg) or to what endpoint therapy will be provided (e.g. infuse normal saline until the SBP is >100 mmHg). This will ensure that the allocation of therapies that are not being studied does not bias the results such that the benefit of the therapy being studied is either obscured or enhanced.",
        "Other considerations for prehospital trauma research": "Considerations unique to prehospital trauma research, as opposed to research that occurs in a hospital environment, include issues related to the local, regional, or state trauma system; interactions between multiple EMS agencies; direct medical oversight; and transport of patients to facilities that are not part of the participating trauma system.",
        "Involvement of the EMS system": "Each EMS agency is part of a larger EMS system. This system includes the 9-1-1 dispatch centers, multiple EMS agencies, and the local trauma centers and non-trauma facilities. Together, these different entities participate to form the complex system of emergency care found in most parts of the United States. As a result, prehospital trauma research projects must account for the participation of all these separate components of the system. A prehospital trauma research project may well affect the dispatchers, multiple EMS agencies, and the receiving trauma centers, some or all of whom may participate directly or indirectly in the project. The researcher must anticipate the possible effects of the project on the involved agencies and, at a minimum, inform them of the project. Alternatively, representatives from each of the involved trauma system components may be brought in to participate in the project planning discussions to solicit ideas and support for the project, and discuss effects of the project on each segment of the system. Getting such \u201cbuy-in\u201d from as many of the involved agencies as possible early in the project can help avoid problems and misunderstandings later, and help assure smooth execution of the research.",
        "Single versus multiple EMS agencies and trauma centers": "Similarly, the project researchers must decide early in the planning whether to involve one or more than one EMS agency and trauma center. Depending on the design of the local trauma system, possible study patients may be brought to a number of local trauma receiving hospitals. By including multiple EMS agencies and/or multiple trauma centers in the study, the researchers will be able to recruit patients from a larger population, thus speeding the execution of the project and increasing the number of patients studied. In addition, this broader population will increase the generalizability of the results and minimize the possibility of bias that is inherent in a single-facility study, where treatment protocols may be specific to that institution. However, the management of the project is made more complicated by involvement of multiple facilities or EMS agencies. More personnel must be trained to carry out the project, and the possibility of protocol violations increases, as the study protocol may be interpreted slightly differently in each location. In addition, the logistics related to updating each site on any changes in the study protocol or any problems encountered are increased with the involvement of multiple sites. The best way to overcome these challenges is to establish an oversight committee, made up of dedicated coinvestigators at each agency and hospital. Each member of this committee would then be responsible for keeping his or her site up to date on the protocols and progress of the study and supervising the execution of the study locally. Early decisions must also be made regarding the enrollment of patients who are transported to non-participating hospitals or trauma centers. Depending on the degree of involvement of the hospital in the study, this may or may not have significant effect on the protocol. For example, if a study only involves the prehospital use of a new tourniquet, with the outcome measure being the estimated blood loss prior to arrival to the ED, then the study protocol can be completed and fully documented during the prehospital phase. In this case, which hospital the patient is delivered to would not necessarily be relevant to the study. However, if the study outcome is the rate of admission of the patients or length of stay in the ED, then involvement of the hospital is critical to protocol completion and recording of data. In such a case, the delivery of the patient to a hospital that is not participating in the study may result in that patient being lost to follow-up. Since it can be difficult to determine hospital destination, especially in a larger urban area with multiple trauma centers, it is generally best to have as many receiving trauma centers formally participate in the study as possible in order to maximize study recruitment.",
        "Roles of direct medical oversight": "Particularly in areas with centralized medical oversight for trauma patients, direct medical oversight can provide support for prehospital trauma research. This support can include assistance with destination decisions, randomization of participants, or contact with receiving hospitals to ensure protocol compliance and facilitate data gathering for study participants. Recent developments involving telemedicine, still image transmission from the scene, and real-time video streaming hold new promise for the active involvement of direct medical oversight in the prehospital care of the trauma patient and associated research.",
        "Data analysis and trauma severity scoring": "Various techniques of data analysis are available to the prehospital trauma researcher. The general purpose of data analysis is to report the effects of a treatment or intervention under study or to define factors that are associated with improved patient outcomes. In studies that involve survival as the outcome measure, logistic regression analysis can be used to establish the influence of other variables that affect patient survival, such as age, trauma mechanism, presence of head trauma, initial vital signs, overall injury severity, and other trauma outcome predictors. The Revised Trauma Score is often used to assess the initial physiological status of the trauma patient, as it is based on the initial Glasgow Coma Scale score and vital signs that are immediately available to EMS providers. The standard method of adjusting for anatomical injury severity is calculation of the Injury Severity Score (ISS) for each patient. This score, originally described in 1974, is an anatomical scoring system based on assigning an Abbreviated Injury Scale (AIS) score for each of six body areas. The three highest AIS scores are then used to calculate the overall ISS. The ISS correlates well with subsequent morbidity, mortality, and other measures of patient severity. However, it cannot be calculated in the field or ED. Other measures of trauma severity have been reported that may be of value in prehospital trauma research. These include changes in vital signs, shock index, point-of-care lactate, and the field trauma triage guidelines developed by the Centers for Disease Control and Prevention.",
        "Military prehospital trauma research": "The military has always had a pivotal role to play in trauma research, including battlefield and out-of-hospital care. The concentrated trauma management experience available on the battlefield has helped physicians and surgeons develop better treatment strategies for centuries. Experiences from past wars, particularly World War II, Korea, and Vietnam, led to improvements in prehospital care concepts that were translated into civilian care systems. A major improvement in military field research capability, the Joint Theater Trauma Registry (JTTR), was implemented during the Iraq war. This database of individuals injured or killed in battle in Iraq and Afghanistan has been a remarkable resource and allowed both military and civilian researchers to better evaluate therapies that were fielded. For example, the universal and aggressive use of tourniquets in these conflicts was controversial when introduced. However, the military experience with tourniquets was well documented in the JTTR. As a result, Kragh and colleagues were able to document a remarkable decrease in mortality and minimal morbidity with the widespread tourniquet use. As a result of this positive and well-documented result on the battlefield, many civilian EMS systems have begun using tourniquets for severe extremity hemorrhage. Another example of this use of the JTTR for evaluation of military trauma care resulted in discontinuation of what initially appeared to be a promising treatment: the use of factor VIIa for traumatic hemorrhage. Initial research demonstrated a potential for decreased bleeding and improved mortality in critically injured patients. However, after fielding VIIa to combat hospitals, patients were discovered to have an increased incidence of thromboembolic events, especially when undergoing long transport to Germany and the US. As a result of monitoring the outcomes of patients receiving factor VIIa in combat, made possible by the JTTR, as well as concurrent civilian trauma center experiences, updated recommendations were issued restricting the use of this treatment. The use of the JTTR by the military has allowed for more accurate and timely changes in the treatment of soldiers and others on the battlefield. In addition, partnership with civilian trauma researchers, such as the American College of Surgeons Committee on Trauma, has given military medical leaders the information they need to regularly update field trauma treatment guidelines. These performance improvement efforts have contributed to the lowest battlefield mortality rates in history."
    },
    {
        "Introduction": "The threat of use of radiological materials or nuclear weapons is at its highest point since the end of the Cold War. This chapter summarizes the environment, dangers, planning recommendations, and response techniques for EMS personnel when involved as providers or victims in a radiological or nuclear event. Selected resources are identified.",
        "Radiation": "Radiation consists of subatomic particles and electromagnetic waves that can interact with matter. Non-ionizing radiation causes excitement of atoms and molecular structures, and ionizing radiation can remove electrons from atoms and break interatomic and molecular bonds, including single- and double-strand breaks of DNA chains. Ionizing radiation has the capability to cause gross surface and subsurface damage, and incrementally impairs the ability of the body to repair those injuries. The latter effect, typically called a \u201cradiation burn,\u201d requires a different medical response than is typical for thermal burns. Ionizing radiation materially damages the immune system, with permanence depending on radiation dose and probabilistic long-term effects, and requires a multifaceted care environment for injury and recovery.\n\nIronically, medical personnel, who have ample scientific training beyond that of the general public, are not immune to fear of the effects of radiation created by the entertainment industry. This was confirmed at a major \u201cdirty-bomb\u201d drill in North Texas in 2004. In that exercise, a large sports venue held 2,500 volunteers and the number of EMS personnel as would be present for an event with capacity of 275,000. State authorities secreted minor radiation sources, commonly available at sporting goods stores, on \u201ctrauma victims\u201d with moulage wounds. When patients arrived at the 35 participating hospitals with varying levels of trauma, and hospital personnel detected the radiation sources, all closed temporarily (went to \u201cdivert\u201d status) due to the presence of contamination. The local public health authority made a decision to require \u201ccontaminated\u201d hospitals to continue to accept contaminated patients, because the authority had received radiation training a few weeks prior to the exercise. In a real-life scenario, fear of radiation can negatively affect operations due to reluctance of medical personnel to handle exposed or minimally contaminated patients. In addition, emergency facilities are likely to be overwhelmed with terrified but uninjured citizens.",
        "Normal radiation environment": "The human species developed in a radioactive world. Ionizing radiation from the sun, rocks, cosmic rays, and from naturally occurring radioisotopes in the environment has continually bathed all life on earth since life began. The background radiation level of the earth is actually less now than at the generally accepted date of Homo sapiens\u2019 first appearance. Approximately 0.03% of the potassium on the earth is potassium-40 (K-40), a radioactive isotope with a half-life of 109 years, which decays while emitting powerful gamma rays. Since K-40 is ubiquitous, any foods that contain potassium are radioactive, and human bodies are radioactive as well. We live in a constant bath of ionizing radiation, and DNA strand breaks and radiation-generated chemically active free radicals result from this radiation. In addition, granite, which is widely found on the earth\u2019s surface and used in buildings, contains small amounts of uranium, which generates many radioisotopes as it decays. Radon, a radioactive inert gas that accounts for over half the background radiation exposure in the United States, is a product of uranium decay. Ionizing radiation is simply everywhere in our existence. Excessive amounts of radiation are problematic because the physical repair mechanisms we have developed to cope with the background radiation on planet earth become overwhelmed.",
        "Radiation threats": "Although the Cold War has ended, the threat of nuclear weapons has not. A number of governments and terrorist organizations have clearly stated the intent to acquire and use such weapons as necessary. In addition, the proliferation of radioisotope sources in medicine and industry has provided targets for terrorist organizations. A substantial effort is underway by responsible governments to protect and secure these sources, but it is possible that a determined group could acquire either a nuclear weapon or radioactive materials sufficient to cause massive destruction, or chaos and panic, with resultant societal disruption and significant expense. In addition, routine uses of radiopharmaceuticals in medicine involve transportation of smaller amounts. Accidents happen and emergency medical personnel could easily be called on to treat accident victims or receive them at their facility.",
        "Types of Ionizing Radiation": "The main types of ionizing radiation are alpha, beta, gamma (and x-ray), and neutron. Each type has specific penetration, and therefore detection, characteristics.",
        "What radiation does not do": "Much has been made by the entertainment industry of the effects of radiation. Spontaneous immediate mutations, burns, and insidious unknown and scary effects are legion in movies, television, and novels. It is important to understand that immediate, dramatic mutations of anatomy do not occur, and that strange genetic anomalies are seen only in successive generations with large population-level doses. Radiation levels in the global environment were higher in the distant past due to naturally occurring radioactive elements, and recent atmospheric nuclear weapons testing raised the radiation background only slightly. The medical worker responding to a radiological incident may be exposed to a high-radiation environment for a short time, but the somatic effects should be similar to a short period of exposure to other physiological stressors such as heat, chemicals, or other repairable phenomena. Long-term effects of lower doses of ionizing radiation are generally probabilistic, and the immediate needs of a population exposed to radiological weapons or contaminants are evacuation, clean-up, and emergency care.",
        "Resources for the responder": "Since the emergency worker has a basic scientific education, understanding of the effects of radiation is somewhat easier to impart than to the general public. It is critical to remember that the effects of radiation are not magic, but are well understood after many years of scientific research. The emergency worker and emergency manager should identify trusted people in the facility or system who can provide accurate and useful evaluation of the risk and give concrete recommendations to ameliorate the radiation effects, while allowing the responder to perform duties. These resources \u2013 people whose livelihood depends on the understanding of radiation and its effects \u2013 are available in most communities, hospitals, and government entities. Immediate resources include nuclear medicine personnel who handle isotopes, detection equipment, and isotope clean-up on a daily basis, and are required to have detectors in their facility. Others immediately available include the facility\u2019s radiation safety officer or radiological incident manager who have more in-depth knowledge of radiation detection and effects. Also, well-trained hazardous materials response personnel, who have extensive training and hands-on experience with detection equipment, may be available. They may also have detection equipment in mobile units. Well-trained incident management personnel with radiation training who have participated in local, regional, and national exercises, may also be available.",
        "Resources in reserve": "Management of a radiological incident requires understanding of the true threat to emergency personnel. An unreasoned response calling for immediate withdrawal of all emergency personnel to extreme distances is unwarranted and possibly negligent. Since fear of radiation is ubiquitous, a radiation specialist may be called on to provide guidance and reasoned response. Such person(s) may not be immediately available, but may be summoned or contacted. It is critical to note that radiation professionals are essential to response organizations when faced with a radiological response. In-depth understanding of radiological science and knowledge of resources available can save time, money, and possibly lives. Every emergency service supervisor should have a list of immediately available contacts who can give concrete applicable advice and information to a responder. Techniques to protect a responder can be simple to implement with available equipment, and responders should be trained in these at every opportunity. Preparation for a radiological emergency is not necessarily an expensive, long-term process, but rather a matter of standard practice modified to fit an additional stressor. Reliable equipment to detect radiation is readily available, portable, and relatively inexpensive. Local medical use of isotopes requires knowledgeable personnel to handle, administer, and detect the isotope. Transportation requires drivers with an understanding of exposure limits and the materials that are being transported. In a massive incident, massive resources must be brought to bear, but immediate local response will be responsible in the first contact with any radiological threat. Local responders must be given clear and proper instruction and training in how to work with and around radiation. Many professional organizations, web sites, and agencies provide detailed information, such as Health and Human Services' Radiation Emergency Medical Management website, and the U.S. Department of Energy, Oak Ridge National Laboratory's Radiation Emergency Assistance Center/Training Site (REAC/TS), which has expert assistance available year-round, 24 hours a day.",
        "How to protect yourself": "Exposure to ionizing radiation is a manageable risk. A basic understanding of the radiation environment and the dangers therein is your primary tool to manage how you and those you supervise can perform with minimal risk.\nRadiation effects can be summarized simply by considering three elements of exposure:\nIrradiation: radiation enters and passes through the body as a field\nContamination: radioactive materials collect on the outside of the body\nInternal exposure: radioactive materials enter the body\nEach has different causes and effects.",
        "Irradiation": "Irradiation means that a person or an object is in a field of radiation, and the effects of that radiation can be reduced by the following three methods.",
        "Time \u2013 Obey the Clock": "Radiation effects are linearly cumulative. In a uniform field and at a steady distance, 10 minutes of exposure totals twice as much total effective dose equivalent as 5 minutes of exposure. It is important for emergency responders to understand the radiation field emitted by each victim. U.S. Environmental Protection Agency (EPA) guidelines for exposure of emergency responders are shown in Table 37.1. If a patient is emitting a radiation field of 100 millirem per hour (1 milliSv), the responder may spend 50 hours on that patient, or work on 50 patients for 1 hour each. For patients with higher radiation field readings, less time is allowed. Obviously, decontamination of the exterior of the patient can reduce the field, but if radioactive shrapnel is present in the patient, danger for surgical teams may exist.",
        "Distance \u2013 Radiation Magic": "Every person has at some time cupped his or her hand around a candle flame or come near a hot light bulb. At a short distance, the flame or bulb feels hot. At a 10 cm distance, the heat is greatly reduced, and at 20 cm may be imperceptible. This principle, known as the inverse square law, applies to ionizing radiation. Radiation received by any object decreases as the square of the distance from the source. So moving away from the patient, or staying at a distance if your immediate presence is not required for a procedure, dramatically reduces your dose. Combining distance and time planning can extend your time to work on an emergency patient, allow you to work on more patients, and increase the resources for responding to an incident.",
        "Shielding \u2013 The Thicker, the Better": "For most radiation sources, dense materials provide more shielding than light materials. Alpha particles will not penetrate skin or clothing or paper. Betas can penetrate approximately 1 cm of flesh, but are stopped by most firefighter protective gear. In the event of high-energy neutron radiation, quantities of plastic and water are required for shielding. Shielding against gamma ray penetration requires substantial quantities of concrete, lead, or water. But in an emergency situation, the person of your coworker, who is 90% water, may be something of a shield. So, standing behind a coworker when you are not needed at the immediate site can help lower your dose. Since shielding for many radiation sources is bulky, shielding is usually the least available tool for protection, unless the characteristics of a shield, such as a wall, are known.",
        "Contamination": "Radioactive materials that collect on the outside of a person (\u201ccontamination\u201d) may be removed by simple mechanical means. Test data from people accidentally exposed to fallout from a nuclear detonation in the Pacific demonstrate that most of the material was removed by disposal of/changing clothing. Recently released Army videos show effective decontamination of troops by using brooms to sweep materials from clothing, and describe sufficient reduction of exposures, which confirms that initial fallout or contamination is in sand-sized grains. Exposed skin may be cleaned with any mechanical cleaning agent, such as soap and water or other surfactants or chelating agents. It is important to keep radioactives from gaining entrance into the body during the decontamination process. Exposed body surfaces such as hair, head, shoulders, hands, arms, and legs, and moist areas under clothing, should be treated as contaminated and washed with copious amounts of mechanical cleaning agent. Of paramount importance is prevention of ingestion of radioactives through any pathway, particularly the respiratory and gastrointestinal tracts. Note that unlike some materials, radiation cannot be \u201cdenatured\u201d or \u201csanitized\u201d by use of any chemical. Decontamination occurs only through mechanical removal.",
        "Ingestion": "The most dangerous exposure route by far is ingestion of radioactive materials. The materials ingested by inhalation, drinking, eating, or through a wound are translocated to specific organ systems, depending on the element, and significant damage can occur to the organ system. The body is an efficient physiological bioconcentrator of many elements, and does not discriminate between radioactive and non-radioactive elements. Iodine is preferentially taken up by the thyroid gland, calcium by the bones, sulfur by the liver and gonads, and so on. When an organ system takes a radioactive element into its physiologic pathway, the damage to that organ system can be amplified by the concentration in that system. For this reason, any emergency responder is advised to wear respiratory protection whenever the possibility of an airborne radioactive contaminant exists. The minimum protection used should be an N-95, R-95, or equivalent mask, but any reduction in the intake of radioisotopes is beneficial. Although there are now pharmaceutical intervention compounds that can remove certain radioactive elements from the body or block the initial uptake by an organ system, the preferential approach is clearly to prevent ingestion.",
        "Effects on Emergency Personnel": "It is difficult for patients presenting in an emergency to have enough radioactive material on their clothes or on their body to deliver a harmful irradiation dose to an emergency worker. Doses to response personnel are limited by regulation to certain specific levels. Below the upper limit of these levels, modern radiation science cannot detect somatic effects of radiation. There may be statistical chances of effects later in an individual's life, but it is unlikely that a responder will suffer an effect. The greater threat to an emergency response worker is the possibility of ingestion of radioactive materials. It is critical that all emergency response personnel become accustomed to immediately donning an N-95 or greater respiratory protective mask when responding to an unknown situation. This may be difficult, since masks hinder communication, particularly for those who need to talk to victims, victims\u2019 families, or numbers of persons. But the lethal ingestion dose for some highly unusual radioisotopes is relatively low. In the poisoning of the Russian agent Litvenenko, the estimated quantity of the polonium-210 delivered was less than a grain of salt. And there are certain non-lethal but common isotopes such as iodine, routinely shipped on trucks in most cities, that should be suspected if any detection equipment shows a reading higher than background. Consequently, the inconvenience and communication hardship generated by the mask is far outweighed by the respiratory protection provided. In addition, if the worker or possible victim needs to drink liquids, a straw should be used to prevent washing contaminants from the lips into the body.\nRadioactive materials for medical use in diagnostic tests are transported in low quantities throughout the world. Shipments occur daily in most major metropolitan areas. The quantities in these shipments are usually not an immediate danger to life and health, and there is ample documentation with each shipment. In the event of a terrorist attack to intercept a shipment, it would be difficult to acquire sufficient quantity of medical isotopes to cause significant harm. Most medical isotopes are of the short half-life variety, can be detected easily by radiation detection equipment, and are transported in well-marked vehicles. Iodine is used for medical activities, but dispersal of this isotope may reduce its effectiveness for injury. In the event of a transportation accident, detection equipment should be used prior to approaching the scene, emergency personnel should don masks, and information on the vehicle or shipment should be acquired as soon as possible.",
        "Dirty Bombs, Exposure Burns, and Ingestion Injury": "The deliberate spreading of a radioactive material could happen in several ways. A radiological dispersal device or other means could spread isotopes over a large area by explosion or release. By definition, dispersing a radioactive material means that it is less concentrated; therefore, the radiation field is reduced by distance. The major medical effect of a \u201cdirty bomb\u201d would be the physical trauma associated with the bomb portion of the device. The medical effect of the radiation from such a device may actually be minimal, since it is difficult to deliver a harmful external dose with dispersed material. The danger would be from the ingestion of radioisotopes. It is certain that this type of incident would cause significant fear responses by a large number of citizens. During an incident in Goiania, Brazil, a city of 1 million people, four people died as a result of breaking open a radiotherapy capsule, and 249 persons were contaminated. A number of persons presented with symptoms of radiation poisoning such as nausea and vomiting. Of those, none were contaminated. But 12% of the population showed up at a local soccer stadium to be checked for contamination. As with a radioisotope transport accident, the number of \u201cworried-but-well\u201d people who are fearful of the effects on themselves or their families could be orders of magnitude above the number of actual victims. Trauma from the explosion of a dirty bomb could be significant, and the victims could be significantly contaminated. For this reason, it is recommended that any EMS personnel responding to an explosion of any sort, or receiving patients who have been affected by an explosion, immediately don masks. Ingestion could lead to significant internal exposure, and remedial pharmaceuticals may be required on an emergent basis. The use of radiation detectors by response personnel would be mandated, both in the field and in a receiving facility. Because the radiation environment could change rapidly, alarm-equipped detectors with reasonable pre-set levels would be useful. Radiation readings taken with calibrated equipment, typically carried by most fire department hazardous materials units, can determine the actual radiation field in the area, and access by emergency personnel can be planned. In the event of the presence of a radiation field, exposure limitations would be enforced. Unusual exposures could be allowed for specific personnel for life-saving and retrieval of injured persons in the radiation field. A far greater hazard may be significant numbers of fearful citizens who feel the need to be \u201cchecked out\u201d by competent medical staff, or who feel the need for decontamination. Medical facilities should be prepared for large numbers of citizens demanding attention if reporting of a traffic accident mentions associated radioactive materials. If there is a possibility of contamination, a simple means to deal with worried but well people would be to establish signage at a medical facility for people to decontaminate themselves while surrendering their clothing, and then donning paper gowns and being examined by trained professionals with radiation detectors. Perhaps the best recommendation to be made with a low possibility for contamination would be for persons who wish to be checked to stay home, remove their clothes and place them in a plastic bag, and then take a shower, put other clothes on, and bring the bag of clothes to a check station, which could be located at an area fire or police station or large gathering venue. An incentive for people to decontaminate themselves would be that if they do, clearance by authorities is faster. Persons who need assistance with decontamination would proceed through a controlled decontamination stream, which would be much slower and monitored closely by response personnel. Materials required for this include heavy-duty plastic bags for clothing, resealable freezer-strength plastic bags for valuables, and temporary clothing for decontaminated persons. The financial effect of a dirty bomb might be significant in the short term, because of the need to clean the area for routine use. Natural phenomena such as weather may reduce the long-term effects of the isotopes, but uptake of biologically active isotopes such as iodine-131 (half-life of 8 days) or cesium-137 (half-life of 30 years) by crops and food animals could prolong the effects. It is important that contaminated areas are controlled and adequately evaluated for realistic decontamination levels. Significant financial resources may be required to \u201cnormalize\u201d an area for use. Without question, national resources would be brought to bear on control and clean-up of any area involved in such an incident.",
        "Exposure Burns": "Exposure burns are generally caused by irradiation, that is, exposure to a radioactive source of activity sufficient to damage cells. This source could be a strong, concentrated \u201ccapsule,\u201d or contamination of the skin over a significant period of time. The burn is not perceived by the individual at the time of occurrence, because humans are not equipped to directly perceive ionizing radiation. The effect of irradiation is to damage the ability of cells to regenerate, which presents at some time after exposure with symptoms similar to a thermal burn. Typically, the burn decreases in severity with distance from the point of exposure on the skin, but the burn can be extremely deep. An exposure burn does not present until weeks or months after the incident, due to the increasing failure of cells to regenerate. Examples are radiological burns from the x-rays during multiple cardiac catheterizations 18\u201321 months post-exposure, and a beta burn from an overnight exposure to a radioisotope thermoelectric generator 6 weeks post-exposure.",
        "Ingestion Injury": "The extremely dangerous effects of ingestion of radioactive materials were highlighted in 2006 in the case of Lieutenant Colonel Aleksandr Litvenenko of the Russian FSB (Federal Security Service, successor to the Soviet-era KGB secret police and intelligence organization). Litvenenko was poisoned with polonium-210, an alpha emitter with an extremely high specific activity (the ability of an isotope to produce radiation), while eating at a London restaurant. Polonium is a metal that binds to the heme portion of hemoglobin, so all tissues in Litvenenko\u2019s body were bathed in high-level radiation. His death occurred 3 weeks after the ingestion. Although the isotope in this quantity is rare and the ingestion deliberate, this incident should serve as a warning to be suspicious of the potential to ingest radioisotopes in an unknown environment such as responding to an explosion or treating patients who present to EMS personnel after an explosive or contamination event.",
        "Nuclear Weapons": "The return of the threat of nuclear weapons has renewed many efforts to prepare for a catastrophic event. The effects of a nuclear detonation of any size would be significant, challenging the resources of any nation to respond. The uncertainty of the location of 50\u2013100 \u201cbackpack nukes,\u201d 1 kiloton weapons manufactured by the KGB for the Soviet Union, and the efforts by states such as Iran to develop weapons, along with the questionable reliability of certain nations that possess nuclear weapons, make a nuclear detonation in a city somewhere in the world more likely than not. The detonation of any nuclear weapon would produce destruction and injury in the immediate area and downwind threats due to fallout. In January 2013, the Institute of Medicine and the National Association of City and County Health Officials hosted a workshop on improvised nuclear devices. Several presentations were made by city, county, state, and federal agencies and private companies describing the effects and management of the detonation of a 10 kiloton device in a major city.",
        "Blindness, Burns, Blast, and Radiation": "The detonation of a nuclear device produces a significant amount of radiation in the visible spectrum. The net effect of this phenomenon is a long-range flash that can permanently blind people who inadvertently look at the flash or at a reflection of the flash. Those who throw their arms in front of their eyes may actually see their bones through their flesh, and may still have permanent damage due to the physical response time for protective actions. The blink reflex takes approximately 200 milliseconds, which may be enough time for permanent injury from the light. The thermal pulse generated by the detonation fireball, which produces energy in the infrared spectrum, comprises 35% of the energy from a nuclear detonation. Any surface exposed to a near-field thermal pulse will experience heat at a rate of 10 calories/cm\u00b2, which can cause spontaneous combustion. Half of the energy generated by a nuclear weapon is expended in displacement of the atmosphere, which is the blast from the weapon. Atmospheric tests on buildings, steel ships, soil, hard rock, water, and all other physical structures demonstrate that there is little that can withstand a nuclear detonation. However, the range of such a blast is entirely dependent on the power of such a device, and the earth's atmosphere provides a damping effect. Local buildings can perturb the effects of the radiation, thermal, and blast effects in such a manner that exposure and traumatic injury may vary substantially. Projectiles thrown by a nuclear blast can travel long distances. Last, the ionizing radiation produced immediately by the detonation comprises a relatively small proportion (5%) of the energy released. This so-called prompt gamma, or immediate release, is a high-energy pulse that irradiates any object according to the inverse square law. Shadowing by concrete structures can reduce exposure. The remaining 10% of the energy released by a nuclear weapon is in the form of fallout, which is residual radioactive materials that are thrown into the atmosphere by the blast, and fall out of the atmosphere over a period of time. Initial fallout, which descends to earth in the first 24-48 hours, comprises 50%-70% of the total radioactivity from the detonation, and is comprised of a mixture of radioisotopes of relatively short half-life and high energy. This early fallout is extremely dangerous due to high radioactivity, and people should avoid exposure to this in any form. Sheltering-in-place at a point as far as possible from the external surface of a building is the primary means of protection, but should be augmented by air filtration. Emergency responders are trained to immediately mobilize to enter the affected zone to save persons, but that training could cause those responders to become immediate victims or die later. Later fallout, which may descend over days or weeks, or may remain in the upper atmosphere for years, comprises 30%-50% of the radioactivity released. This occurs primarily in the form of small particles, and may be longer half-life isotopes with lower radioactivity. Respiratory protection is advised for anyone downwind of a detonation. For this reason, it is critical to know and understand the \u201cwind rose\u201d for your location. Knowing the direction of travel of the wind could mean the difference between life and death. If patients are received who have been in a fall-out area, or a patient is irradiated by a large source, use the Andrews lymphocyte nomogram to determine the level of exposure. Note that if a person is exposed to radiation, a major factor in his or her recovery is prevention of infection. A general hemogram shows maximum vulnerability at 30 days postexposure.\nAnother effect of a nuclear weapon is the radio flash, or electromagnetic pulse (EMP). When a nuclear weapon is detonated, the large number of gamma rays released has enough energy to actually knock electrons from atoms of gases such as oxygen and nitrogen in the atmosphere. These free electrons spin in the earth\u2019s magnetic field, and give off energy in an intense flash. This EMP has the potential to cause damage to any electronic circuit. An EMP could damage any communication device, control circuits for medical equipment, computers, networking equipment, power systems, and vehicles. Refrigeration of medicines and electrical support of patients could be damaged, for a short time to months. Planning for this possibility consists of installing power generation equipment in shielded areas, treating penetrations for transient suppression, and other technologically complex procedures, but can also be as simple as removing antennas from radios when in charging cradles, and contingency planning if all power, communications, and vehicular transport are unavailable. The extent of EMP damage would depend on the size of the weapon and the altitude at which detonation occurs. A ground burst will cause an EMP of varying radius, e.g. 10 kt would be about three miles. That same size burst, if detonated above the atmosphere, could destroy all electronics over a large distance, measured in tens or hundreds of miles.",
        "Impact on Medical Care": "It is clear from numerous drills that the medical community suffers from many of the same fears that are widespread among the general population. Often, when radioactive contamination is detected in even low levels, medical facility administrators assert that their facility is \u201ccontaminated\u201d and thus closed to new patients, including formal declarations of diversion. Minimal levels of radiation exposure necessitate only minimal disruption to facility operations or personnel activities, and understanding by managers of such levels is critical. In a radiological event, it is possible and even likely that emergency facilities, ambulances, and other response equipment will become slightly contaminated. The high sensitivity of radiation detection devices produces highly audible readings from even minimal contamination that is not a threat to emergency workers. Radiation safety professionals or other trained workers must accurately evaluate the threat to emergency medical personnel. There are three myths that can paralyze medical response. The first is that radioactive contamination is highly dangerous and requires extraordinary measures. The facts are these: radioactive contamination is not immediately dangerous to life and health, is easily managed and contained using air-borne and contamination infection control practices, and, unlike biological or chemical agents, presents little hazard to medical staff, unless inhaled or otherwise ingested. A second myth is that decontamination of the patient is the highest medical priority. The facts are these: there are few, if any, legitimate reasons for withholding treatment due to radioactive contamination. Radioactive contamination may present issues over the long term (years), but is not usually an immediate threat to life and health. If the patient requires immediate treatment, treat the patient while protecting yourself. Later you can decontaminate the patient and yourself. The key is to understand radiation levels and to avoid ingestion of radiological materials. You can manage the risk. A third myth is that you need special skills to handle radioactive patients. The facts are these: radioactivity cannot be sensed by the human body, so radiation meters (e.g., Geiger counters) are needed. They are easy to use, and most larger fire departments now have meters. Contamination surveys are easily learned and performed. Decontamination is essentially a soap-and-water clean-up (in many cases as simple as a sponge bath).",
        "The Greatest Hazard: Overwhelming Public Demand": "It is worth reiterating that the public demand for emergency services to ameliorate fear is likely to be the greatest challenge to EMS in any minor radiological event, and an exacerbating condition in a major event. A large percentage of the population in your area may present to emergency departments, ambulances at or near the scene, or even your on-scene command post, with emotional demands to receive your services immediately. Security of emergency personnel must be maintained to allow successful treatment of truly injured persons.",
        "Summary": "Radiation effects are science, not magic. The cultural fear of radiation is global. Emotional responses from the public can obscure the knowledge base about radiation physics, and drive societal and political activities that have no basis in science. The effects of radiation on humans are well understood. Even more important is the understanding of what radiation does not do. Exaggerations of radiation effects for entertainment purposes have encouraged the public to expect dramatic and fictional responses rather than measured, understood effects.",
        "Simple, Clear Steps": "Emergency medical services workers can take simple, clear steps to detect the presence of radiation, protect themselves from the radiation, and reduce the effects of radiation exposure and contamination on facilities and coworkers. Radiation detection instruments work well, and in the hands of trained personnel, are dependable and effective. Protection is simple. 1. Prevent ingestion of radioisotopes at all costs, even at the cost of communication. 2. Focus on time, distance, and shielding when responding to any radiological incident. 3. Remember that time of exposure is linearly cumulative, but exposure is reduced by the square of the distance. 4. Simple decontamination means mechanical removal of materials, and most comes off the patient or the worker with removal of clothing.",
        "Pharmaceuticals": "Fortunately, compounds are available that can be used to reduce the total effective dose equivalent that the worker or patient receives from ingested radioisotopes, if administered in time. The National Institutes of Health list an excellent reference paper, and the Centers for Disease Control and Prevention maintain an excellent web site. Pharmaceutical compounds corresponding to certain isotopes are available to either prevent absorption or actually cause the body to excrete the isotopes in a shorter time. The critical factor in most of these treatment regimens is timely administration. Stockpiles should be present, and most have a long shelf-life. Recent research has focused on the hematopoietic and gastrointestinal syndromes produced by radiation exposure, and new pharmaceuticals, such as granulocyte-colony stimulating factor medications used in radiation oncology on cancer patients, hold great promise for treating radiation injuries.",
        "Conclusion": "Providing an effective medical response to a radiological or nuclear incident is possible for the EMS responder. Education and training are important in overcoming fears of the effects of radiation. Tools are available that must be used, and resources from experts in radiation protection are available."
    },
    {
        "Introduction": "Death by motor vehicle crash/collision (MVC) is currently the fifth leading cause of death for all Americans. The American Automobile Association reported that the economic costs associated with traffic crashes were $299.5 billion, based on 2009 data. Over the past decade, vehicle-related death and injury rates have steadily decreased. In 2002, the occupant fatality rate per 100 million vehicle miles of travel (VMT) was 1.51; from 2010 to 2011 it was 0.98/VMT \u2013 a historic low. Despite this improvement in fatality rates, there were still over 5 million MVCs in the US during 2011. These crashes resulted in about 2.2 million injuries and just over 32,000 deaths.",
        "Effect on EMS": "In the US, someone dies in an MVC every 16 minutes. Moreover, fatal crashes are far outnumbered by crashes with non-fatal but serious injuries requiring urgent medical attention. Therefore, a significant percentage of EMS calls relates to MVCs. While many crashes involve only single vehicles, there may be multiple occupants in that vehicle. In a crash involving more than two vehicles, many more EMS resources may be required. Likewise, if public transportation, such as trains or buses, is involved, the need for those resources is greatly expanded. The hazards present at the scene of the MVC are many and varied. Continued high-speed traffic flow on freeways represents a significant threat to the safety of the rescue crews. Spilled fuel can result in a fire risk and broken glass and sharp metal edges can also prove hazardous to the unprotected EMS provider. Grounded power lines and hazardous materials being transported on the roadways present additional risks. Emergency medical services physicians and providers may not have the personal protective gear to operate in such environments. Fire department response is often required to address hazardous issues. Rural or smaller agencies may not have the heavy extrication equipment necessary to access trapped patients. Regardless of whether the EMS system is fire department based, additional resources (e.g. rescue, law enforcement) are often used at the scene of an MVC.",
        "Motor vehicle crash injury biomechanics": "During a crash, different parts of an occupant's body are subjected to sudden acceleration or deceleration. Injury results when tissues are disrupted by local concentrations of physical force generated by a crash event. Morbidity and mortality occur when vital organs absorb energy beyond their tolerance. The ability to tolerate physical forces varies considerably from individual to individual. Clinically, it is important to remember that those at either end of the age spectrum (children and the elderly) are particularly sensitive to serious injury due to the reduced ability of their tissues to absorb energy. Acceleration and deceleration are defined as changes in velocity over time, measured in G forces (the weight of objects in earth's gravitational field). In healthy, non-elderly, adult individuals, the upper end of transient G force that can be tolerated is about 30G. Both speed and stopping distance contribute to the overall G force experienced during an MVC. Gs increase by the speed squared, while doubling the stopping distance cuts the Gs by half. Automotive safety equipment such as seat belts, airbags, and vehicle deformation (crumple) zones effectively increase the stopping distance for the vehicle occupant during a crash. Four possible collisions occur during a MVC. 1 The vehicle strikes another object and the crushing of the vehicle\u2019s structure absorbs energy. Vehicles with a greater capacity to deform absorb more energy and effectively increase the stopping distance. During this phase occupants continue in motion. 2 A second collision occurs as a passenger strikes the vehicle's interior or restraint system such as seat belt and airbags. 3 Internal organs continue in motion until they strike surfaces such as the skull or chest wall. 4 Loose objects and unrestrained occupants can strike the person, resulting in further injury. Poor automotive design, absence of airbags, and lack of seat belt use decrease the stopping distance and thereby increase the G force experienced by a vehicle occupant.",
        "Safety restraints": "Inertia causes occupants of a car to be moving at the same speed as the car. In a crash, the car comes to an abrupt halt and the occupants inside continue at the speed the car was traveling until their bodies are stopped by objects such as the windshield, instrument panel, or steering wheel, if they are not wearing seat belts. Stopping an object's momentum requires force acting over a period of time. A seat belt, anchored to the vehicle, is designed to apply the stopping force to more durable parts of the body over a longer period, allowing the occupant to \u201cride down\u201d the crash as the vehicle crumple zones crush and absorb the energy, and helps protect the body from serious injuries. In contrast, unrestrained occupants do not get the additional \u201cride down\u201d time and, at higher speed, hit the vehicle interior with weaker parts of the body, e.g. upper abdomen to steering wheel. The use of three-point seat belts reduces the risk of fatal injury in passenger car occupants by 45% and the risk of moderate-to-critical injury by 50%. The risks are reduced by 60% and 65% respectively for light truck occupants. Airbags spread the force required to stop the occupants over a large part of their bodies, minimizing local concentrations of force that can disrupt tissues and cause injury. The airbag has the space between the passenger and the frontal or side components of a vehicle and a fraction of a second in which to work. Even that tiny amount of space and time is valuable, however, if the system can slow the passenger evenly rather than forcing an abrupt halt to the occupant\u2019s motion. The National Highway Traffic Safety Administration estimates that belts alone reduce fatalities by 45%, and when combined with airbags, there is a 50% overall reduction in mortality.",
        "Motor vehicle crash types": "Even with the most advanced vehicle restraint systems, crash injuries still occur. Injuries are caused by physical forces, and the direction and magnitude of these forces are dependent on the configuration of the crash. Therefore, the type of crash (e.g. frontal, side, rollover) largely determines the injury patterns seen. Properly evaluating the crash scenario will help EMS physicians and providers to predict the most likely injuries they will need to treat. Relaying accurate information about the crash event to the medical team will enable the proper assessment and care of the patient in the emergency department. Major crash types include planar crashes, rollovers, and a host of unusual crashes. Frontal crashes typically make up about 42% of all crashes; side and rear crashes occur in almost equal numbers, 25% and 22% respectively. While rollovers only make up approximately 9% of all crashes, they tend to be the most highly injurious. Each of these crash types has its own injury patterns and concerns.",
        "Motor vehicle crash types - Planar crashes": "These crashes are characterized by forces occurring in two dimensions, x and y (flat). They include frontal, side, and rear impacts. Additionally, any of these crashes can be further classified as a narrow-impact crash. Typically, this means the vehicle strikes a narrow object, such as a tree or light pole, which then crushes into the vehicle further than would be the case if the vehicle had struck a broad object.",
        "Motor vehicle crash types - Frontal crashes": "Automotive manufacturers have created \u201ccrush zones\u201d to deal with this most common type of crash. The front of the vehicle is designed to absorb the energy from the crash and to minimize intrusion of vehicle structure into the occupant compartment. In assessing a crash, it is very important to differentiate between damage to the exterior of the vehicle and intrusion of vehicle structure into the passenger compartment of the vehicle. Significant intrusion of vehicle structure into the interior of the passenger compartment is much more predictive of serious occupant injury than external vehicle damage. Since the advent of frontal airbags, head and facial injuries have become much less common. While chest injuries such as rib fractures are still quite common, particularly in the elderly, incidences of aortic and heart injuries have substantially decreased. Currently, the most common serious injuries observed in frontal crashes affect these body regions in descending order of frequency. 1 Lower extremities 2 Pelvis 3 Thorax 4 Head 5 Abdomen",
        "Motor vehicle crash types - Side-impact crashes": "Most side-impact crashes involve two vehicles: a \u201cbullet vehicle\u201d that hits the \u201cstruck vehicle\u201d in the side. In assessing and describing side-impact occupants, it is important to determine whether they were \u201cnear-side\u201d or \u201cfar-side\u201d occupants relative to the crash location. Near-side occupants are at greater risk for severe injury. It is also important to remember that side-impact crashes are generally far more dangerous than frontal crashes. Therefore, when arriving at the scene of a side-impact crash, barring extenuating circumstances, medical priority should typically be given to the near-side occupants of the struck vehicle, followed by the far-side occupants, and then the front-seat occupants of the bullet vehicle, and finally the rear-seat occupants of the bullet vehicle. Side impacts, those that strike the right or left planes of the vehicle, can be further characterized as being L-type (i.e. striking in front of or behind the passenger compartment) or T-type (i.e. striking within the passenger compartment). The T-type side-impact crashes are more dangerous for vehicle occupants than L-type. Side impacts tend to be more severe as there is less space for \u201ccrush zones\u201d and therefore very little way of absorbing energy. Narrow T-type side-impact cases are particularly dangerous for the occupants as there is far greater intrusion into the passenger compartment. There has been an increase in side protection in the form of curtain and seat-mounted airbags but these safety features are far from common in the fleet. Currently, the most common serious injuries observed in side crashes affect these body regions in decreasing order of frequency. 1 Head 2 Thorax 3 Pelvis 4 Abdomen",
        "Motor vehicle crash types - Rear crashes": "For vehicle occupants this is generally the least dangerous of the planar impacts. The large crush zone in the back of many vehicles tends to absorb much of the energy of the incoming vehicle. In addition, the occupants are protected by their seats.",
        "Rollover crashes": "These crashes are characterized by forces occurring in three dimensions: x, y, and z. There is a type of rollover, called an arrested roll, which indicates the roll has been stopped by an object in the crash zone such as a utility pole or tree. Arrested rolls are associated with greater intrusion of vehicle structure into the passenger compartment and a greater risk of injury to the occupants. Restraint use has a huge effect on injury risk and patterns in rollover crashes. Rollovers are problematic for the occupants as the rotation during the crash event throws them upward and outward. As the roof hits the ground, the occupants dive toward the roof. If the roll continues, occupants may slide out of their seat belts and continue to be thrown around the interior of the vehicle outward toward the side windows. As a result, ejection of the occupant is much more likely in rollovers than other crash types. Complete or partial ejection of the occupants is associated with the most severe injuries and must be suspected in all rollovers due to the movement experienced by the occupants. Indeed, EMS findings of complete or partial ejection are a field triage criterion. Finding complex lacerations with road debris or \u201croad rash\u201d on any part of the body constitutes \u201cpartial ejection.\u201d Due to the likelihood of occupant ejection in rollover crashes, it is very important that EMS canvass a large area around the vehicle to detect ejected occupants. In addition, the vehicle damage makes this type of crash hard to assess, adding to the complexity of these cases. Roof intrusion is an important indicator of potential injury in rollover crashes. A rule of thumb is that there is approximately 2 feet of distance between the bottom of the window/top of door panel and the roof. If half of that distance is gone, there has been 12 inches of downward roof intrusion. The most common serious injuries observed in rollovers affect these body regions in descending order. 1 Thorax 2 Abdomen 3 Head 4 Spine 5 Extremities",
        "Unusual crashes": "Further complicating matters are the unusual types of crashes that may occur in real-life situations. These include incompatibility between the vehicles involved in the crash (e.g. an SUV striking a compact car), underride (e.g. a passenger vehicle rear-ending a semitrailer and traveling under the restraining bar), and override (e.g. a semi crashing into a passenger vehicle and driving up and over the back of it). Incompatibility between vehicles involved in a crash is based on three elements: mass, stiffness, and geometry. In the US, the popularity of SUVs and trucks, with their greater height, stiffness, and weight, has increased the risk of injuries suffered by occupants of the vehicles they strike in a crash. These vehicles are designed to perform heavy-duty functions and consequently they can be dangerous to the occupants of lighter vehicles. In addition, their stiffness makes them less able to protect their own occupants in severe crashes, as they are less able to absorb some of the crash energy. Incompatible side impacts are especially problematic as they compromise the ability of a struck vehicle\u2019s safety systems to properly sense the crash and protect occupants, thus increasing the risk and severity of injuries. The occupants of the more vulnerable vehicle frequently sustain injuries higher in the body, such as the head and chest. These injuries can compromise the ABCs. Rapid response and proper triage are therefore essential. Ejection can be a problem in these crashes as well. Partial ejection, where part of an occupant\u2019s body strikes something outside the vehicle, such as an intruding hood or tree branch, is associated with very high risk of serious injury and thus is a criterion for transport to the highest level of care available. Any crash may contain elements of several of these types, confounding EMS providers, physicians, and crash investigators.",
        "Crashes involving vulnerable road users": "In addition to occupants of vehicles, there are other vulnerable populations sharing the roadways, including pedestrians, pedal cyclists, and motorcyclists. While these numbers are lower than those reported for 2002, all these populations experienced more fatalities and injuries in 2011 than 2010. These patients tend to be more seriously injured than vehicle occupants as they do not have the protection offered by a motor vehicle.",
        "EMS crash assessment priorities": "When approaching the scene of a crash, there are things to look for. \u2022 Unrestrained occupant(s) \u2022 Possibly ejected occupants: \u25cb complex open wounds \u25cb empty child safety seat \u25cb broken window or windshield \u25cb rollover \u2022 Intrusion into the occupant space The intrusion criterion for high-risk auto crashes is 12 inches at the occupant seating location or 18 inches at any interior site. One key rule of thumb to remember is that a seat is approximately 24. Therefore, if vehicle structure intrusion is such that only half the normal seat width remains, the occupant seated there is at high risk of serious injury (10% risk of ISS 15+). In addition, the footwell area is approximately 24 and the lower part of the dashboard is approximately 12 of intrusion. The crash and vehicle information at the scene is essential for properly triaging the patient, and this information can predict the most likely injuries. Properly relaying this information to the medical team will enable the optimum assessment and care of the patient.",
        "Extrication": "First responders are well aware that the quicker they remove occupants from a damaged vehicle and get them to treatment, the better the outcome will be. It is imperative that clinical care begins at the scene and is a priority during the extrication process. Integration of EMS into the incident command structure at an MVC can ensure that clinical care of the patient is not under-emphasized during extrication. Whenever safely possible, it is desirable to have an EMS provider (wearing appropriate personal protective equipment) inside the vehicle with the patient while extrication proceeds. Packaging patients for removal from a motor vehicle typically involves manually stabilizing the cervical spine and then immobilizing the spine with a cervical collar and any one of a variety of spine immobilization devices. When necessary, spine immobilization and patient removal is a personnel-intensive process requiring a team approach.",
        "Field triage": "At the scene of any MVC or other event involving traumatic injury, EMS physicians and providers must identify those patients who are at greatest risk for severe injury and then choose the most appropriate facility to which to transport them within the trauma system. This decision process is known as \u201cfield triage\u201d and is based on a practice algorithm called a The first Field Triage Decision Scheme was published by the American College of Surgeons (ACS) in 1986, with subsequent updates in 1990, 1993, 1999, 2006, and 2012.",
        "Unique motor vehicle crash problems": "There are many hazards involved in dealing with MVCs. In many cases, EMS physicians and providers will be watching for traffic and avoiding the usual detritus that comes from a crash, such as broken glass, spilled fuel, and jagged metal pieces. EMS physicians and providers must also be ready to protect themselves from bodily fluids and blood-borne pathogens.",
        "Batteries": "Many of the systems in today's vehicle fleet contain electronic control units, which can include controls for airbags, door locks, electronic windows, seats, and telematics. Gasoline-hybrid vehicles also have high-voltage cables, which are identifiable by the use of orange insulation. For this reason, an important initial step for EMS physicians and providers arriving on scene is to make sure the ignition is off, remove the key, and disconnect the battery. This shuts down the power source for all electronic control units and avoids any chance of injuries from the electrical components of the vehicle.",
        "Airbags": "Emergency medical services physicians and providers need to be especially careful about undeployed airbags. There have been cases where EMS personnel have been injured when an airbag deployed as they were packaging the patient. There are several reasons why an airbag restraint system (ARS) may not have deployed during the crash. For instance, frontal airbags are designed to not deploy in rollover, rear, or side impacts. Side airbags are not designed to deploy in frontal or rear impacts. If the right front passenger seat is not occupied, the firing of those airbags may have been suppressed by design. In some cases, the collision may not have been severe enough to set the airbag off, or there could be a system malfunction that prevented the bags from deploying. There are clues that an ARS may be present. Sometimes there is a label on the visor, instrument panel, or window. A small, low glove box can indicate a large dash-mounted airbag. Tags or letters may be embossed on the areas containing an ARS, such as the seats, pillars, roof rails, or instrument panel. Some tags to be alert for include: SIR, ARS, SRS, Airbag, SIPS, HPS, ACRS, ITS, and KAS. Rescue workers should treat undeployed airbag restraint systems as explosive devices. \u2022 Disconnect the battery. \u2022 Disconnect any ARS connectors found. \u2022 Do not place any objects against the module.",
        "Emerging technology": "Advanced Automatic Crash Notification Vehicles in the fleet have a large number of sensors. Some of them monitor the presence of an occupant. Others monitor for data suggesting that a crash may be occurring. These data are constantly analyzed by the computer systems within the vehicle and in the event of a crash, the computers will trigger the deployment of the safety systems in the optimal configuration for the type and severity of the crash being detected. In many vehicles, some of these data will be sent via cellular networks to alert emergency responders and provide useful information that can improve postcrash care for the occupants. The ability to send this information is called Advanced Automatic Crash Notification (AACN). Currently, crashes sensed as severe enough to be associated with a 20% or greater risk of ISS 15 injury to the occupants are identified by telemetry providers notifying EMS.",
        "Available education": "The International Center for Automotive Medicine at the University of Michigan has created a website dedicated to training law enforcement, EMS, and medical personnel. This website is located at www.crashedu.org and contains various educational modules for first responders. Continuing medical education credits are also available."
    },
    {
        "Introduction": "Woman abuse, wife assault, domestic violence, relationship terrorism, and intimate partner violence (IPV) are all terms that have been used to describe the violence that occurs between two people in an intimate relationship. Although domestic violence includes IPV, it also refers to violence against other family members; therefore, for the purpose of this chapter, the term IPV will be defined as the intentional use of tactics to gain and maintain power and control over the thoughts, beliefs, and conduct of an intimate partner. The term partner may be defined as a current or former girlfriend, boyfriend, spouse, or common-law spouse. Tactics used to gain control in IPV create fear, isolation, and the entrapment of one partner. The majority of non-fatal intimate partner victimizations occur at home. The EMT or EMS physician is in the unique position to attend to the patient in the home and observe the environment in which the violence took place, as well as the behaviors of the victim and abuser along with their interactions with each other. Being aware of these behaviors will allow the EMS provider to identify situations in which abuse may not yet have escalated to physical violence, thereby allowing early intervention.",
        "Scope of the problem": "Violence against women is well documented by the World Health Organization (WHO). IPV occurs in all countries, regardless of social, economic, religious, or cultural status. Although it is recognized that violence occurs against men in both opposite and same-sex relationships, the prevalence of women as victims is overwhelmingly greater than men. Therefore, this chapter will focus on male violence against female partners. About one in four women and one in seven men have experienced severe physical violence. Women are three times more likely to report that they have been beaten, choked, sexually assaulted, or threatened with a gun or knife and therefore more likely to require medical attention. Domestic violence is a leading cause of injury to American women between the ages of 15 and 44 and is estimated to be responsible for 20\u201325% of emergency department (ED) visits by women. One in five homicides involves killing of an intimate partner.",
        "High-risk groups": "Part of identifying IPV is awareness of the high-risk groups. Although it already has been established that women are a risk group, there are subgroups that are at even higher risk. Women who are separated or divorced report higher rates than women of other marital status. Aboriginal women are three times more likely to experience spousal violence than non-aboriginal. Visible minorities report a rate of IPV of 5%. Women with disabilities are 1.5\u201310 times as likely to be abused as non-disabled women, depending on whether they live in the community or in institutions. At least 4\u20138% of pregnant women report suffering abuse during pregnancy, and 39.2% of same-sex cohabiting women, and 23.1% of men, reported being raped, physically assaulted, and/or stalked by a marital or cohabiting partner at some time in their lifetime.",
        "Understanding intimate partner violence": "Abuse often begins in a close, mutual relationship, which over time becomes exclusive, allowing the abuser to isolate the victim. Violence can appear gradually or suddenly, but generally there is a period of 'testing.' This may begin with verbal abuse and then progress to sexual and physical abuse. Shoving and pushing can escalate to punching, kicking, and assault with blunt and penetrating weapons.",
        "Cycle of violence": "Many abusive relationships undergo a cycle of violence, which occurs in three stages. In phase one, tension builds and the woman increases her efforts to please the abuser in hopes of avoiding violence. The woman may intentionally trigger the abuse at a time when she feels the violence is inevitable to decrease the stress she feels about the impending violence, or to be in control as to where and when the violence will occur. In phase two, violence erupts and may increase in frequency and severity over time. Phase three represents a \u201choneymoon\u201d phase in which the abuser apologizes for the abuse, may purchase gifts, blames the victim, and offers rationalizations (e.g. \u201cIf you only didn\u2019t\u2026 I wouldn\u2019t\u2026.\u201d). This phase may become shorter over time.\n\nThe cycle of violence can also occur generationally because it is passed through the family. Children witnessing abuse learn that it is tolerated or even appropriate behavior and a way of gaining power and control, and therefore may repeat the behavior in their own relationships.",
        "Intimate partner violence as a health care issue": "Studies report that about one in four women seeking care in the ED for any reason is a victim of violence (one in three treated for trauma), and 37% of female patients who are treated in the ED for violent injury have been injured by intimate partners.\n\nHealth care providers are being encouraged to universally screen for violence in the ED and primary health care settings. This means that all women over the age of 12 are asked about abuse, not only those in whom injuries appear suspicious. The National Violence Against Women survey revealed that 125,000 (17.5%) female victims of assault used ambulance services. Because EMS personnel are often the first responders to situations that involve violence, it is critical to be able to identify, ask about, and respond appropriately to the unique situations that involve IPV. If violence can be identified early then there is an opportunity to intervene, thereby improving the health and lives of women and children and stopping the cycle of abuse.",
        "Health effects of abuse": "Many women living with abuse experience more than just physical injuries such as fractures and soft tissue injuries; they may present with psychiatric and medical conditions. Between 2001 and 2005 the US Department of Justice statistics reported that fewer than one-fifth of victims reporting an injury sought treatment following the injury. Approximately 8% of female and 10% of male victims were treated at the scene of the injury or in the home. Females who experienced an injury were slightly more likely than their male counterparts to seek treatment at a hospital. EMS might be called to a scene at which the patient is experiencing any of the aforementioned conditions. Through noticing the environment, patient injuries, and/or interactions between the patient and her partner at the scene, the EMS provider may be able to identify IPV.",
        "Emergency medical services provider safety": "If EMS is activated through a 9-1-1 call for IPV, it is important to have law enforcement secure the scene before EMS access. If EMS personnel arrive at the scene of a non-disclosed IPV situation and feel that they are at risk, law enforcement should be called. Once the scene is secure, the providers can proceed with assessing safety in the immediate area where the patient is located to provide medical assistance. Patients should be assessed in the appropriate sequence with the primary survey, ABCs, and life-saving interventions undertaken, followed by a secondary survey and further history. While on the scene, EMS providers should keep the following in mind. Avoid confronting the abuser. Do not place yourself physically between a couple who are arguing. Ensure that an escape route such as the door is available. Do not let the abuser get between you and your escape route. Be aware of your jurisdiction's legal requirements with respect to reporting to law enforcement. Some states require EMTs responding to an injury sustained during a crime to report to police; others will allow or mandate the patient to decide the best action to take. Requirements may be different for physicians.",
        "Assessment and examination": "On the initial interaction with the patient, EMS personnel may find there was a delay in seeking help and/or that this patient may have experienced repeated calls and visits to the ED for injuries.",
        "Physical assessment": "The physical assessment may reveal injuries such as abrasions, bruises, burns, dislocations, lacerations, bites, fractures, abrasions, or marks on the neck consistent with strangulation, petechial hemorrhage in the eyes, a combination of old and new injuries, and/or patterned injuries to the head, face, neck, throat, chest, breasts, back, abdomen, or genitals. Injuries that suggest a defensive posture, such as those found on the hands or ulnar aspect of the arms, are suspicious. Patients may also experience mouth and dental trauma. It may also be found that the patient\u2019s or partner\u2019s description of accident is inconsistent with the observed injury. If this is the case, EMS should document both what is reported and objective observations.",
        "Behavioral assessment": "Once the patient is medically stable, EMS personnel should observe the environment as well as the behaviors and interactions between the people at the scene. The abusive partner\u2019s behavior may include: hovers over her, insists on being present while she is being examined, answers for the woman, is overly friendly with the care provider, or appears kind or overly concerned. Conversely, he may also minimize the injury, lack sympathy, make remarks about her, or blame her for the violence/accident. The woman\u2019s behavior may be evasive and guarded interactions, including saying nothing in front of her partner, minimizing the seriousness of her injury, avoiding eye contact, and looking to her partner for guidance.",
        "Asking about abuse": "Once an EMS provider has made a determination that this call or injury could be a result of IPV, as part of the overall patient assessment, he or she should ask about abuse in a confidential environment, and respond appropriately to support the patient. The goal of asking about abuse is to make a supportive connection and convey the message that abuse is a health issue. This may help to lessen the patient\u2019s isolation. Options may then be reviewed so that the patient is empowered to make informed choices for herself and her children. If the patient denies abuse, she will at least be left with the awareness that she can access EMS assistance when required, if and when she chooses to disclose.",
        "Separating couples": "Asking about abuse must be done in private, away from anyone who may intimidate the victim. Ideally, children should not be present because they may repeat information they hear to others. This could create a dangerous situation if disclosed information were repeated to the abuser. Separating the abuser may require some creativity and is a challenge in the out-of-hospital setting. Two options are to have one EMT take the partner into another room to ask more health history questions or wait until the patient is alone in the back of the ambulance. It is important to make clear to the partner beforehand that the ambulance is for patients only. The EMT should be conscious of what he or she is saying and tone of voice. Do not inadvertently give messages that the patient is to blame or should follow your advice, such as saying, 'What did you do to cause this?' or 'How can you love this guy?'",
        "Encouraging disclosure": "There is no question that will elicit a disclosure if the patient is not ready. Do not force a disclosure. Should the EMS provider suspect abuse based on physical or behavioral observations, use the observation in the question, such as, 'I am concerned that this injury may have been caused by someone hurting you. Did someone hurt you?' or 'I noticed your partner doesn\u2019t like to leave you alone, how do you feel about that?' If the EMS provider is practicing universal asking/screening, then something that contextualizes the question would be more appropriate, such as, 'Violence against women has become a health care issue; therefore, I ask all my female patients if they have ever experienced abuse/violence as a child, adolescent, or adult.' If she says 'yes', the EMS provider can respond with the following questions. 'Are you safe now?' (Determine the location of the perpetrator.) 'Would you like to talk about it?' (If the EMS provider does not have the time, then provide 24-hour IPV hotline/helpline numbers for support.) Have you talked to anyone else about this? What do you need right now? When people experience IPV their power and self-determination are taken away. EMS care should endeavor to empower the patient. Ways in which this can be done are explaining and asking permission before performing medical procedures, if the patient\u2019s condition allows; sitting at or below the patient\u2019s eye level; building trust by being direct and compassionate in responding to her questions; and being clear about violence against women being a crime and that this was not her fault. Even in the out-of-hospital environment, women need a supportive, non-judgmental atmosphere in which to feel safe disclosing abuse. Expressing concern, conveying that you believe her, and providing validation for her experience are effective ways of offering support. If possible, provide options such as a sexual assault/domestic violence care or response center, police involvement, safety planning, and shelter referrals. The EMS provider should respect the decisions the patient makes; it might not be what the provider would have done given the situation, but the patient is the expert of her life and knows what she can deal with at this time.",
        "High-risk indicators and concerns": "Factors that have been shown to be related to increased risk of further violence in relationships include increasing frequency and severity of violence, using or threatening to use a weapon or to kill the woman, access to guns, perpetrator using drugs and alcohol excessively, and violence in pregnancy. Women who have been injured through IPV often decline transport to the hospital. Therefore, they will not have the availability of resources such as nurse examiners or social workers to provide them with support or referrals. Hence, the EMS provider\u2019s knowledge of safety plans and the resources in the local community may be beneficial.",
        "Culture and domestic violence": "North America has become very culturally diverse and continues to attract people with a range of cultural norms, values, attitudes, and beliefs about illness and violence and the treatment response to a variety of conditions. As each individual responds to stress and violence differently, much of each person\u2019s reaction will be influenced or affected by his or her cultural background. During times of physical/emotional stress, verbal understanding may be decreased whether or not the patient is English speaking. It is important to have as accurate an account of the events as possible in order to collect appropriate evidence and medically clear the individual. It is helpful to limit the amount of technical language, professional jargon, and common expressions that may be interpreted literally, such as 'tachycardia' or 'I am feeling under the weather.' Speak slowly, not loudly. Face the person; it may or may not be appropriate to make/sustain eye contact. Use short, simple sentences. Repeat and/or rephrase questions and summarize often to ensure your understanding. Ask open-ended questions. Questions that require only a 'yes or no' answer do not tell you if the questions have been correctly understood. If the interpreter is a spouse or other family member, bear in mind that not all facts may be disclosed due to the potential ramifications of reporting a domestic violence call. Abusive men of all cultures use similar power and control tactics. However, when a family has immigrated to North America there may be some additional tactics employed. It is important to consider the family structure in diverse cultures, particularly what is the hierarchy and who has the power within the family. On an individual level, women may feel fear, shame, and powerlessness, and therefore remain silent. Their view on marriage may be that they are there to provide a sexual service and therefore sexual assault does not exist in a marriage. They may also be struggling with how they will be perceived if they disclose; going against the family and getting a spouse in trouble may be interpreted as a sign of weakness, as may seeking help. When considering the impact on the family/community, the family may deny that sexual/domestic violence exists in the desire to succeed and reestablish oneself. Other considerations are fear of being ostracized for bringing shame upon the family, fear of retaliatory violence from the perpetrator and his supporters, fear of being shunned by the community, uncertainty and mistrust about how the police/system will respond, fear of deportation. Cultures differ in their styles and attitudes toward decision making and disclosure. Assume there will be differences between cultures and within cultures. Use your power and privilege to empower others. Create safe spaces for these sensitive conversations and respect others' decisions even if you do not agree.",
        "Safety planning": "Women seek strategies aimed at preventing and responding to violence. The EMS provider should ascertain what she has done in the past to keep herself safe, what is working, and what is not working. Because a woman's level of risk may change over time, safety plans need to be flexible. Assess what the patient's major concerns are at this time by asking open-ended questions such as, 'What are you worried about most right now?' This aids in building a trusting relationship and views the patient not as a victim but as a strong capable participant in her future. The more she directs the safety planning, the more likely she is to adhere to it. The resources listed at the end of this chapter provide more information about safety planning.",
        "Referrals": "There are many options that EMS and other emergency providers may offer to victims of IPV. The EMS physician should make referrals in a way as to empower the patient to make her own decisions. The person in the situation is the best judge of what is safe to do right now. It is important for emergency providers to be aware of crisis lines, along with the appropriate agencies and organizations in their jurisdiction which offer services for victims of IPV. Sexual assault/domestic violence care or response centers can offer crisis intervention and support, documentation of injuries and photographs, safety planning and risk assessments, referrals to shelters, and other advocacy services. There may be mandatory reporting policies in your jurisdiction and all EMS personnel should be familiar with police services and mandatory reporting requirements. Shelters usually have counselors available 24 hours a day and provide a safe place for someone to flee relationship violence. Child protection agencies offer protective and referral services as well. Legal agencies may be available for victims of IPV.",
        "Preserving evidence and documentation": "When performing a physical assessment, the EMS provider may note patterns of blunt injury, lacerations, or penetrating wounds. It is therefore important to know these patterns and appropriately document if the injury does not fit the mechanism described. Be careful not to disturb the crime scene or destroy possible evidence, such as by removal of the patient's clothing. If anything needs to be removed to attend the patient, describe the condition of the clothing and place it in a paper bag. Cut around bullet holes or stab wounds, not through them. The manner in which clothing is removed or altered should be noted (e.g., 'during resuscitation, patient's shirt torn open, tearing off four buttons'). If any furniture needs to be moved to get to the patient, this should also be documented. Use the patient's own words when describing how she received the injuries, who assaulted her, and when. A detailed history of all aspects of the assault need not be taken as part of immediate care. The EMS provider should write what is pertinent to the care and treatment of injuries. Documentation should occur at the scene or as soon as possible after attending to the patient. Should a case go to court, the patient care record will be the only documentation the EMS provider will have of this event. Documentation should be objective, without accusations or value statements, accurate, specific, legible, and complete.",
        "Realistic expectations": "It can be difficult to bear witness to abuse. Often health care providers feel powerless in their efforts to make a significant difference in someone's life. It is important to remember that dealing with abuse is a process and each person has the right to set his or her own agenda and work at his or her own pace. The role of EMS is to provide medical treatment and support and empower patients to make the decisions that are right for them at a time when they feel it is safe. EMS cannot 'fix' a victim or the situation. At times, providers may not agree with the decisions patients make, but they are the experts of their lives. Domestic violence does not always end when women leave the relationship. Statistics show that the most dangerous time is when she has decided to leave or soon after she has left. Women can be trapped in and may return to relationships many times for a variety of reasons before making a final break. Understanding why people stay in abusive relationships and how to keep them safe is key when providing care to a victim of IPV. A strong multidisciplinary team approach is essential and will result in the most appropriate and beneficial patient-focused care for people experiencing violence in their lives. Therefore, ensure that all essential information and impressions are communicated to ED staff.",
        "Conclusion": "A call to a residence where IPV has taken place can be one of the most difficult calls to which EMS respond. It is vital for the scene to be secure before the EMS personnel enter the premises. On calls where IPV is not initially identified in the call, but is suspected once on the scene, it is the responsibility of EMS personnel to ask and assess the patient\u2019s immediate safety. In instances where the patient declines transportation, knowledgeable EMS personnel can provide support and resources and suggest immediate safety planning. If the patient accepts transport to the ED, ensure that all relevant information is reported to the health care provider taking responsibility for the patient."
    },
    {
        "Introduction": "Sexual violence is a critical global issue that affects millions of people worldwide, claiming a victim every 45 seconds according to the American Medical Association. EMS personnel are certain to encounter sexual assault victims, and are often the first to interact with the victim after the assault. It is crucial that EMS physicians and personnel, as well as EMS medical directors, understand the psychosocial, medical, and legal aspects of sexual assault. Sexual violence has been defined as any form of sexual activity with another person without her or his consent. The assault may include forced kissing, fondling, attempted or completed penetration, forced masturbation by the victim or to the assailant, forced participation in or looking at sexually explicit photos, sexual harassment, exhibitionism, and voyeurism. Both women and men can be victims of sexual assault; however, the majority of assaults are perpetrated by men against women and children. Therefore, for ease of pronoun use, she or her will be used here in any reference to a victim. The National Intimate Partner and Sexual Violence Survey reports that nearly one in five women (18.3%) and one in 71 men (1.4%) in the United States have been raped at some time in their lives, including completed forced penetration, attempted forced penetration, or alcohol/drug-facilitated completed penetration. It is important to note that sexual assault is one of the most underreported crimes. Fewer than one in ten victims report the crime to the police. Most women will confide in family, friends, co-workers, doctors, and/or nurses. Reasons for not reporting include embarrassment, fear of being blamed or not being believed, and fear of reprisal from the assailant or court proceedings. Sexual assault is often attributed to overwhelming sexual desire. It is anything but. All forms of sexual assault are the misuse of power and control over another person with the intention of abusing and humiliating the victim.",
        "Drug-facilitated sexual assault": "Drug-facilitated sexual assault (DFSA) is the term used to describe cases of sexual assault in which the victim is unable to consent or resist because she has been rendered incapacitated or unconscious due to the effects of alcohol and/or drugs. DFSA may result when drugs or alcohol are administered without the victim's knowledge, or through the perpetrator taking advantage of a person who is already under the influence of drugs/alcohol. These crimes are less likely to be reported to law enforcement agencies because of the inability of the victim, due to drug-induced amnesia or fear, to describe the events.",
        "Consent issues": "Sexual assault occurs when there is no consent on the part of the other person. Consent is an active choice and constitutes a voluntary agreement between two persons of legal age to engage in sexual activity. A spouse can be charged with sexually assaulting the other spouse in cases of intimate partner violence. Previous consent to sexual activity does not mean that consent is not required the next time the other person seeks a sexual encounter. The following are examples of situations of non-consent and sexual assault: Someone who is under the influence of medication, drugs, and/or alcohol; A child; Someone who expresses in words, gestures, or by his or her conduct a refusal to engage in or continue sexual activity; Someone who submits to sexual activity because of force or threats against her or others; Lies are used to obtain consensual sex; A third person says \u201cyes\u201d for someone else; The accused is in a position of power/authority over someone; The accused is a blood relative; A doctor, nurse, or other health care professional performing an unnecessary internal examination.",
        "Myths": "Myths are used to condone or deny sexual assault. Accepting myths as reality contributes to the way society responds to and may influence the reporting of sexual assault. Some of the widely held myths are: the only way a rapist can really force a woman to have intercourse is by using a weapon; women who do not actually physically fight back have not been raped; if the attacker is drunk at the time of the assault, then he cannot be accused of rape. Providers should understand that sexual assault can affect anyone (including males, children, and the elderly) and is not typically accompanied by physical injury or signs of trauma.",
        "Male sexual assault": "Use of weapons and brutality are reported more often in male sexual assault. Therefore, males may sustain more physical trauma than females. The most common forms of assault that males experience are receptive anal and/or oral intercourse and forced manual genital stimulation. The male patient may feel guilty about having been assaulted because of a belief that males are supposed to be able to protect themselves. This feeling can be compounded if the male also experienced an erection and/or ejaculation during the assault. Both these responses can occur as involuntary reactions to extreme stress. A male does not have to be sexually aroused to have an erection. Given that most assaults committed against men are perpetrated by other males, a common misunderstanding for assaulted heterosexual males is that he will become homosexual after the assault.",
        "Psychological care of the patient": "Many victims of sexual assault do not suffer life-threatening injuries; however, they do experience psychological trauma. Therefore, after assessment for and management of physical injuries, support becomes the EMT\u2019s priority. During a sexual assault, power and control are taken away from the person; care should be directed at restoring the person\u2019s self-determination through decision making with respect to her care. Sexual assault is the only crime in which the victim is often considered to have some responsibility and have contributed to the assault by the way she dressed, spoke, or acted, or her location at the time of the assault. No one asks or deserves to be sexually assaulted: EMTs should always treat patients with respect. The patient will experience a multitude of emotions, including but not limited to shock, disbelief, confusion, guilt, self-blame, terror, anger, and lack of trust. These emotions may be evident or the patient may be very composed. The patient may even block out the events if they are too much for her to cope with at the time. The type of response she receives from the first person to whom she discloses can affect how she views her situation and subsequently deals with it. Some of the most important things an EMT can do in the initial interaction is to connect with the patient through introducing himself or herself, using the patient\u2019s name, maintaining eye contact, and using a calm, even tone when speaking. It is important that the EMT proceed on the presumption that an assault has occurred; it is not the EMT\u2019s role to decide whether or not an assault occurred. Responses to the patient should be non-judgmental and intended to reassure the patient that she is safe and that the assault was not her fault. Many victims buy into the myths surrounding sexual assault, and it is thus important to be able to help the patient distinguish between myth and reality. People respond to crisis in a variety of ways, from crying to being calm and cooperative to laughing nervously. All are normal responses and it is important to help the patient understand this if she is concerned about how she is responding. A controlled response from a patient does not mean that the assault did not happen. She may also be concerned that she did not do enough to resist the assault; therefore, she should be reassured that she did what was necessary to prevent any further harm. If she is alone, the EMT should ask her if she would like a support person to be called.",
        "Physical care of the patient": "In addition to suffering severe emotional trauma, the patient is at risk of genital or other physical injuries. Police-reported data show that the victim and accused were known to each other in 82% of sexual assault incidents. Perpetrators can include a family member, friend, neighbor, or work colleague. Tactics used in these cases may focus less on physical force but rely on verbal intimidation, tricks, and administration of drugs or alcohol. Therefore, the absence of injuries is as consistent with sexual assault as their presence. In rape by a stranger, the likelihood of force is increased, either through verbal threats and physical force, or the element of surprise. People respond differently when confronted with sexual assault. Some may succumb to escape any further injury or death, whereas others may fight to escape. Regardless of how the patient responded to the situation, it is important that the EMT reassure her that she handled the situation appropriately. After securing the scene and ensuring provider safety, life-saving medical care is the EMT\u2019s top priority; therefore the patient\u2019s ABCs should always be assessed and assisted as needed. The EMT should make detailed notes of any physical side-effects and injuries of sexual assault, among which may be: loss of consciousness, drowsiness, dizziness, disorientation, difficulty speaking or moving, or hallucinations. Note: it is important in cases in which DFSA is suspected that the EMT document the patient\u2019s level of consciousness, affect, and any symptoms or signs of drug effects: bites on the face/breasts; suction injuries of the neck; skeletal muscle tension and general soreness; complications of strangulation: marks, petechiae in the face and conjunctiva; evidence of being restrained, such as any patterned injury, rope marks around wrists/ankles, or fingertip bruising on arms or legs; abrasions, lacerations, and bruises on a variety of areas on the body, head, behind the ears, neck, thighs, knees; broken teeth, jaw, black eyes; clumps of hair missing due to hair pulling. Unless there is severe hemorrhage or other evidence of life-threatening genital injury, this area should not be examined. Genital and/or anal injuries sustained in a sexual assault can be difficult to visualize and therefore assessment of these areas should be left to a trained sexual assault examiner in the emergency department. Unnecessary examination may leave the patient feeling revictimized and may disturb vital forensic evidence. Typical injuries include small tears, bruises, abrasions, redness, and swelling. In forced oral penetration the EMT may note similar injuries around the mouth along with petechiae on the palate and uvula and a torn frenulum. Bruising behind the ears may occur from the assailant\u2019s use of physical force in an oral assault. It is the EMT\u2019s responsibility to ask appropriate questions, assess, and document observations and findings. Questioning should be kept to a minimum: the EMT should only ask questions that are required to do a physical assessment. Hospital staff and law enforcement will conduct a more thorough examination and investigation. Depending on the circumstances of the sexual assault, the patient may be at risk of sexually transmitted infections and/or pregnancy. She should be advised that medical treatment for pregnancy and human immunodeficiency virus is time-sensitive and can be obtained from a sexual assault care center or emergency department.",
        "Culture and sexual assault": "As each individual responds to stress and violence differently, much of their reaction will be influenced or affected by their cultural background. Some immigrants have a command of the English language and others may require an interpreter to assist them in communication. Remember, during times of physical/emotional stress, understanding may be decreased. In cases of sexual assault it is important to have as accurate an account of the events as possible in order to collect appropriate evidence. Limit the amount of technical language, professional jargon, and common \u201cexpressions\u201d that may be interpreted literally. Speak slowly, not loudly. Face the patient; it may or may not be culturally appropriate to make/sustain eye contact. Use short, simple sentences. Repeat or rephrase questions and summarize often to ensure your understanding. Ask open-ended questions. Questions that require only a \u201cyes\u201d or \u201cno\u201d do not tell you if the questions have been understood correctly. Touch is a major part of health care response, used to provide physical care and emotional comfort. While all humans require some degree of touch, cultural norms and context will influence what is appropriate. In cases of sexual assault, a person may not wish to be touched in any way. It is best to ask prior to touching if it is OK, i.e. \u201cMay I touch your arm, to look at the injury?\u201d Let the patient know when you are going to touch her. Experiences of touch will vary depending on the patient\u2019s age and sex, the body part involved, and her interpretation of touch. The interpretation could be that of a caring gesture or control. In order to respond to a patient with the bigger picture in mind, it is important to understand the role of the individual, the family, and the community with respect to attitudes towards violence, sexuality, and sexual behaviour. There will be gender variations and the value of virginity to be considered. Other effects on decision making will be with respect to \u201csaving face\u201d and the effect this disclosure will have on the family and the community and what social supports they may have. Affecting their decision to report may be their understanding of trust, power, and privilege with respect to the authorities, their immigration and resettlement experience, and the effect of racism and fear of retaliatory violence from the perpetrator and his supporters. Expect that there will be differences between cultures and within cultures when people experience sexual assault. While you may feel the most appropriate plan of care is to take the patient to the hospital and involve police, this may not be the best course of action in the long run. Focus on the patient\u2019s strengths and avoid judgment by altering your perspective and seeing it from her point of view.",
        "Legal aspects": "In cases of sexual assault, there are two crime scenes where evidence can be collected immediately: the location where the assault occurred, and the victim of the assault herself. There are several aspects that need to be proven for a sexual assault to have occurred: Both victim and perpetrator were together at the same location; There was a sexual act; There was no consent. Documentation should be prepared on the assumption that the information may eventually be presented in a court of law. It is imperative that the documentation be accurate, comprehensive, objective, legible, and timely, either during or immediately after giving care.",
        "Preservation of evidence": "Evidence can be verbal or physical. The EMT should document any information that the patient volunteers, using exactly the same words the patient uses in quotes. This information may be used later in court as an \u201cexcited utterance,\u201d which is a spontaneous statement that concerns a shocking event while under stress caused by that event. For example, the patient makes a statement such as, \u201cHe threatened to kill me if I told anyone.\u201d This might influence the sentencing process after the perpetrator is apprehended and convicted. When considering physical evidence, every effort must be made to preserve that which might link the perpetrator to the victim and the sexual assault. DNA evidence can be collected from blood, hair, saliva, semen, and skin. Therefore any areas on the patient that may have been exposed to any of the aforementioned body fluids or substances must be protected. For example, if the perpetrator kissed, licked, or bit any area of the patient, care should be taken not to disturb this area. If the patient is aware of having scratched the assailant, then the fingernails should be protected by either advising the patient not to scratch or do anything with her hands or by wrapping them in a paper bag or linen of some sort to preserve whatever evidence might be present. Do not use plastic (i.e. plastic gloves) because plastic may cause biological evidence to deteriorate. Do not remove clothing or disturb bodily evidence unless necessary for medical assistance due to injuries. Clothing and other items removed during examination should be placed in separate paper bags. The appearance of the clothing should be carefully documented (e.g. torn, stained). Bullet holes or other defects mechanically inflicted should be cut around and not through because these may be instrumental in determining the angle or distance from which a weapon was used. Characteristics of wounds (e.g. location, type, size, color) should be documented as they appeared before any medical interventions. If a ruler or measuring tape is not available for precise measurement of any wounds, a well-known comparison should be used (e.g. size of a quarter, length of a dollar bill). Any foreign debris or objects embedded in the wound should be noted. Debris removed from a wound should be inserted into a paper bag or clean container. Tubes or drains should not be inserted into wounds. Therapeutic puncture sites should be indicated with circular markings so that these areas can be distinguished from injuries received during the assault. Should the patient need to urinate, defecate (if she cannot wait), or vomit, this evidence should be preserved. Generally a sterile or clean container will suffice (e.g. urine specimen container). This is especially important if a DFSA is suspected. Any containers the patient believes may have been used in the drugging, such as a water bottle or coffee mug, should also be collected. Food or drink should not be given to any patient who has been orally assaulted. Patients should avoid brushing teeth or gargling until evidence has been collected. Forensic evidence deteriorates quickly; the highest quality evidence is collected within 72 hours of the sexual assault. If at all possible, it is important to get the patient to a sexual assault care center for evidence collection as soon as possible, should she decide to involve law enforcement. The EMT must be aware of legal obligations and requirements with respect to reporting to law enforcement. Some jurisdictions require EMTs responding to an injury sustained during a crime to report to police; others will let the patient decide the best action to take.",
        "Chain of custody": "Evidence collected from the patient becomes part of a chain of custody. This is the method of obtaining, transporting, and storing evidence that demonstrates proof that evidence collected at the crime scene or from the patient is the same as that being presented in court. Paper bags, sterile containers, tamper-resistant tape, and chain of custody forms are rarely carried on ambulances. If these are not available, the EMT should devise a way to preserve evidence in which the item is sealed. The date and time the item was collected and removed, a description of the item, the location from where it was collected, and the EMT\u2019s initials should be documented on the item. Items collected should be placed in an area where their integrity can be maintained, allowing the EMT to testify that there has been no opportunity for tampering with the item. Once law enforcement is involved, the item(s) should be signed over to the police. This may include the ambulance stretcher sheet because there may have been a transfer of hair, debris, or other fibers from the patient/perpetrator. This sheet should be carefully folded on itself and provided to the police or ED.",
        "Sexual assault nurse examiners/sexual assault response teams programs": "Many states and provinces have sexual assault response teams (SART) or sexual assault care centers (SACC) that have specially trained sexual assault nurse examiners (SANE) available 24 hours a day. These nurses attend to the medicolegal needs of a sexual assault patient. They provide prophylactic treatment for sexually transmitted infections and pregnancy along with a thorough physical assessment and evidence collection. EMS physicians and EMTs should be aware of the treatment centers in their area.",
        "Conclusion": "The manner in which the EMS physician and EMT react to a disclosure of sexual assault will affect how the patient will view her situation, respond to treatment, and engage in the recovery process. The life of a person who is sexually assaulted is changed forever. A thoughtful and supportive response along with appropriate evidence preservation by the EMT can be the first step in a patient\u2019s journey to recovery and prosecution of the perpetrator. Local sexual assault crisis hotline numbers should be readily available and the patient encouraged to seek counseling or to speak to someone she feels would be supportive."
    },
    {
        "Introduction - Epidemiology": "Trauma is the leading cause of death worldwide and in the United States for people under the age of 44. Blunt trauma from motor vehicle accidents, falls, or other mechanisms can result in a range of orthopedic injuries. Recognition and management of orthopedic injuries is an essential component of any EMS system.",
        "General approach to management": "The prehospital management of a suspected orthopedic injury begins with assessment of potential life threats. Obtaining a history that includes the mechanism of injury is important to develop an index of suspicion for associated injuries. Prehospital providers should first assess and address the airway, breathing, circulation, and disability of any injured patient. Once the primary survey is complete, an orthopedic evaluation is part of a comprehensive secondary survey. Open fractures and injuries with neurovascular compromise require special attention. Acute hemorrhage control is the first priority for the open fracture in the field and can generally be accomplished with direct pressure. Any exposed bone should be dressed with a sterile saline moistened dressing. The decision to reduce a fracture or dislocation in the field is situation dependent, and should be based on presence of neurovascular compromise, anticipated extrication and transport duration, and provider training and experience. Pain management is an important component of the prehospital care for any orthopedic injury and should ideally be addressed prior to moving the patient to the ambulance. Pain management modalities include immobilization of the affected limb and intravenous opiates.",
        "Anatomy, fractures, and dislocations- upper extremity neurovascular exam": "For all upper extremity injuries, both nerve function and vascular patency must be assessed early and repeated frequently, particularly after any manipulation, splinting, or patient movement. The radial, ulnar, and median nerves should be assessed for both motor and sensory function in all injuries. The axillary and musculocutaneous nerves should be assessed in more proximal injuries. The vascular exam consists of palpating both the radial and ulnar pulses as well as the brachial artery in more proximal injuries. For injuries distal to the wrist, nailbed capillary refill should be assessed.",
        "Anatomy, fractures, and dislocations - Clavicle": "Clavicular fractures are generally uncomplicated and can be managed in the field with sling and swathe placement. Assessment should include a complete neurovascular exam of the limb on the affected side as there is a risk of damage to the underlying subclavian vessels and brachial plexus as well as possibility of pneumothorax. The clavicular articulations to the sternum (sternoclavicular [SC] joint) and acromion (acromioclavicular [AC] joint) should be assessed as well. AC joint injury can be diagnosed clinically and should be managed with a sling and swathe in the field. SC joint injuries most commonly occur as a result of vehicle accidents or sports injuries and are divided into less serious anterior dislocations and more serious posterior dislocations. While field treatment for both is immobilization, prehospital providers should have a heightened index of suspicion for serious intrathoracic injury with a posterior dislocation, in particular pneumothorax, great vessel injury, and tracheal injury.",
        "Anatomy, fractures, and dislocations - Scapula": "A patient with a scapular fracture will generally present protecting the arm on the affected side and with local tenderness. Management consists of sling and swathe placement and analgesia. Up to 75% of patients with scapular fractures will have additional injuries due to the significant mechanism of injury. Providers should carefully examine the patient for rib fractures, pneumothorax, or upper arm injuries.",
        "Anatomy, fractures, and dislocations - Humerus": "Fractures of the humerus can be divided into three categories: proximal, midshaft, and distal. Axillary nerve and artery injuries have been recognized in up to 50% of displaced humeral fractures. Humeral shaft injuries are most common in active young men and elderly osteoporotic patients and can be associated with radial nerve injuries or vascular injuries to the brachial artery or vein. Field management is the same as for other shoulder injuries.",
        "Anatomy, fractures, and dislocations - Elbow": "The elbow joint is composed of the articulations of the distal humerus, proximal radius, and ulna. The brachial artery and the nerves of the forearm and hand travel in close proximity. It is the third most commonly dislocated joint after the shoulder and knee. Supracondylar fractures are among the most common fractures in children. The primary fracture patterns in adults include flexion and extension, the latter being more common. The majority of elbow dislocations (90%) are posterolateral, with the mechanism of injury being fall on an outstretched hand. Commonly associated neurovascular injuries include entrapment of the ulnar nerve and the brachial artery. It is difficult to differentiate an elbow fracture from a dislocation in the field without x-rays, and as such, it is recommended that EMS providers splint all suspected fractures or dislocations in the position found. However, gentle reduction is recommended in a severely angulated fracture or one with significant neurovascular compromise. If reduction is attempted, the elbow then should be splinted at 90\u00b0 with the forearm in supination with a posterior moldable splint and a sling and swathe placed.",
        "Anatomy, fractures, and dislocations - Shoulder": "Glenohumeral joint dislocations are the most common major joint dislocation encountered, and are generally the result of an indirect blow with the arm in abduction, extension, and external rotation. Anterior dislocations are the most common and can be identified clinically in the field with some reliability. In general, the patient will present guarding the affected arm with mild abduction and external rotation. Posterior dislocations are rare, usually the result of a mechanism of injury such as a seizure, electrical shock, or direct anterior blow to the shoulder, and while carrying a similar associated fracture rate they are less likely to have neurovascular injury. Inferior and superior dislocations are even less common. When examining a suspected shoulder dislocation, close attention should be paid to the axillary nerve. Vascular injuries are rare but when they do occur, will generally involve the axillary artery. Associated fractures occur in 15\u201335% of shoulder dislocations and can include the humeral head (Hill\u2013Sachs lesion), anterior glenoid lip, and greater tuberosity. Although these fractures generally do not change management, pre-reduction x-rays are recommended, and field reduction should typically not be attempted. There are exceptions to this rule, in particular for patients with known recurrent dislocations and athletes on the field with appropriately trained staff. Providers should splint the extremity in the position found with a sling and swathe. A short board splint can be placed along the medial upper arm for extra stability, particularly in the presence of a suspected humeral head fracture.\n\nIn the n the event of a spontaneous reduction, providers should still splint and transport, as radiographs and follow-up will be needed.\n\nRotator cuff injuries may be associated with shoulder dislocations or may present independently. Complete evaluation of the rotator cuff could become more commonplace prehospital practice, particularly within a community paramedicine setting. However, no validated rules currently exist to exclude fracture or dislocation, and a patient with an acute shoulder injury would likely benefit from transport to the hospital.",
        "Anatomy, fractures, and dislocations - Forearm": "While the unique fracture and dislocation patterns of the forearm are of interest to the emergency physician in determining definitive management, they are less important to the prehospital provider. Field management involves splinting with a posterior mold or short boards in the position found. Indications for attempted field reduction are similar to other fractures, although neurovascular compromise in these fractures is less common than in injuries of the humerus or elbow. Fractures to the proximal ulnar, olecranon, and radius are treated similarly to other fractures and dislocations about the elbow.",
        "Anatomy, fractures, and dislocations - Wrist": "Fractures of the distal radius and ulna are the most common wrist fractures, followed by the carpal bones, notably the scaphoid and triquetrum. Distal forearm fractures should be immobilized in the position of function, if tolerated, or the position found. Carpal fractures can be immobilized in either a short board or commercial wrist splint. Once splinted, the extremity may be placed in a sling and swathe to further reduce movement. Distal neurovascular assessment should be documented. EMS providers may be trained to assess for snuff box tenderness to assist in identifying potential scaphoid fractures. Carpal ligamentous injury frequently occurs in conjunction with bony injury and should be splinted similarly based on physical exam findings of tenderness.",
        "Anatomy, fractures, and dislocations - Hand/fingers": "Hand and finger injuries are rarely life threatening but can be emotionally disturbing to the patient and provider. Once attention is appropriately turned to the hand injury, function of the median, radial, and ulnar nerves should be assessed as previously outlined. Vascular status can be assessed through capillary refill, which should be less than 2 seconds. Flexor and extensor tendon function should be tested in each finger and compared between hands. Fractures and dislocations of the phalanx should be splinted as found, and buddy taping can be used to stabilize the finger itself prior to placing the affected hand in a wrist or short board splint. Field reduction may be appropriate in some situations. However, ideally the patient should be transported to the emergency department for a peripheral nerve block prior to reduction. Case reports do exist of successful paramedic performance of a digital block and subsequent reduction, and this is a potential future expansion of practice. While metacarpal fracture management and follow-up vary depending on radiographic findings and patient activity, field management is unchanged and involves splinting. One hand injury that deserves special mention is the high-pressure injection injury, which always requires transport to the ED for evaluation and possible surgical intervention.",
        "Anatomy, fractures, and dislocations - Pelvis": "Although pelvic fractures are relatively rare among orthopedic injuries, they are associated with high mortality (10\u201315%) due to both the presence of concurrent severe traumatic injuries and the pathophysiology of unstable pelvic fractures. The most common mechanisms associated with pelvic fractures involve the transmission of significant amounts of force such as through high-speed motor vehicle collisions, pedestrians hit by automobiles, or significant falls. Anterior-posterior compressive forces are often associated with the highest degree of hemodynamic instability and mortality. Such fractures cause significant disruption to the pelvic ring, resulting in widening of the pelvis, tearing of the iliac ligaments and shear force injuries of the iliac vessels. The predominantly venous hemorrhage spills into the retroperitoneum and expanded pelvic cylinder. If left uncontrolled, this hemorrhage can be fatal due to the large potential space of the unstable pelvic vault. Pelvic injury should be suspected in any patient with significant traumatic injuries of the head, spine, thorax, abdomen, or multiple extremities. Signs of shock should raise suspicion of an unstable pelvic fracture in patients without outward signs of fracture. Other signs and symptoms of pelvic fractures may include perineal or flank hematoma, or blood at the penile meatus or vaginal introitus. Obvious bony instability of the pelvis with light palpation is a clear finding of pelvic fracture. However, the absence of external findings does not exclude the presence of an unstable pelvic fracture. The examiner may gently compress the pelvis to test for stability, but caution is advised, as this may exacerbate an unstable fracture or concomitant bleeding. Clinical management of the suspected pelvic fracture, as with other major trauma, includes immobilization and rapid transport to a trauma center. Given the risk of vascular and hemodynamic compromise, vital signs and distal neurovascular status should be monitored closely during transport. In addition to general immobilization techniques, use of a pelvic binder may be indicated. Whether it is a commercial product or an improvised sheet, the principle behind the use of a pelvic binder is to reduce the potential space of the pelvis and to tamponade the associated venous bleeding. Epidemiological and biometric data suggest that the application of a pelvic binder reduces mortality. Although routinely used in prehospital care in the past, there is a theoretical concern for worsening of vascular injury and hemorrhage due to vessel laceration by bony fragments. Therefore, care should be taken when applying a binder.",
        "Anatomy, fractures, and dislocations - Lower extremity": "Similar to the upper extremity, a thorough lower extremity neurovascular exam should be completed and documented before and after any intervention or patient movement. The tibial, sural, superficial peroneal, and deep peroneal nerves should be assessed for both motor and sensory function. The femoral and obturator nerves should be assessed when there is concern for pelvic and hip fractures. The vascular exam involves palpation of the popliteal, dorsal pedal, and posterior tibial pulses.",
        "Anatomy, fractures, and dislocations - Hip": "Hip fractures are common, accounting for more than 300,000 hospitalizations per year in the United States. Age and sex are major risk factors: 80% of hip fractures occur in patients aged 75 or over, and nearly three out of every four patients are female. More than 90% of hip fractures are due to elderly falls but may also result from high-energy trauma (such as from a motor vehicle collision). Classically, patients present with pain, and shortening and external rotation of the affected limb. However, these findings can be inconsistent depending on the anatomical location of the fracture. Prehospital providers should rely on their standard trauma assessments to assess injuries to the hip. As a large amount of force is needed to fracture a hip in younger patients, concomitant injuries are found in 40\u201375% of cases. Among the elderly, providers should evaluate for precipitating factors, other fall-related injuries, and conditions related to delays in accessing care. Depending on patient condition, further prehospital management could include general orthopedic trauma care, appropriate splinting, and aggressive analgesia as tolerated. While it is possible to provide skin traction using a commercial device for hip fractures, a 2011 Cochrane review found no benefit from preoperative traction of any sort. Hip joints are inherently stable. Dislocations are generally caused by high-energy trauma, most often motor vehicle crashes. The force required to dislocate a hip is so great that 95% of these patients will have other major injuries as well. Ninety percent of hip dislocations are posterior dislocations of the femoral head, while the remaining 10% are either anterior or medial (associated with acetabular fractures). Patients will most commonly complain of severe hip pain and limb deformity in the setting of a significant mechanism of injury. Due to the high rate of concomitant injuries, prehospital providers should generally approach those with suspected hip dislocations as major trauma patients. The focus of care should be on prompt packaging and transport, as these patients have significantly increased rates of serious neurovascular complications if the dislocation is not reduced within 6 hours. However, appropriate splinting and analgesia should not be ignored.",
        "Anatomy, fractures, and dislocations - Femur": "As with hip dislocations, femoral shaft fractures are often seen in younger patients as a result of major trauma. Of note, large volume hemorrhage can occur in the thigh, with potential development of distal limb ischemia or clinically significant hypovolemia. Owing to the large size of the thigh, compartment syndrome is rare. These fractures can be readily diagnosed in the field, as the thigh is generally painful, swollen, and deformed, while the affected limb appears shortened. Although there are limited data pertaining to their application in the prehospital setting, commercial traction splints have long been the standard of care used by EMS personnel in the management of isolated femoral shaft fractures. Their use is discussed later in this chapter.",
        "Anatomy, fractures, and dislocations - Knee": "Knee injuries include fractures, dislocations, and damage to the supporting structures of the joint, including all ligaments and menisci. When splinting knee injuries, it is often best to immobilize the limb in the position found or in the position of comfort. Care should be taken not to splint the leg fully extended, as this may compress the neurovascular bundle against the posterior tibia. Although relatively uncommon, knee dislocations require additional care in the prehospital setting. Tibiofemoral dislocations can result from motor vehicle collision, sports injuries, and even falls. These injuries have the potential to cause severe vascular damage at the site of the popliteal artery, leading to distal ischemia. Prompt treatment and transport are crucial to prevent long-term damage to the affected limb. In extreme cases (such as severely delayed transport or other extenuating conditions significantly delaying definitive care), properly trained and authorized prehospital providers may consider attempting reduction in the field, if necessary to restore distal circulation. Of note, up to 50% of knee dislocations spontaneously reduce prior to ED presentation. Fractures of the tibial plateau can occur from both low- and high-energy trauma and are seen in both young adults and the elderly. Those occurring at the medial plateau have the potential to damage the peroneal nerve and/or the popliteal artery, leading to distal neurovascular impairment. Further complications can include the development of compartment syndrome, although this generally occurs 24\u201348 hours after the time of injury.",
        "Anatomy, fractures, and dislocations - Leg injuries": "The tibia is the most commonly fractured of all long bones. Eighty percent of the time there is an associated fibular fracture, due to their adjacent positioning and attachment via the syndesmotic ligament. This ligament can transmit energy between the bones such that they may be fractured at non-adjacent sites. The lower leg can be immobilized with a variety of devices, including cardboard, padded wood, and vacuum splints. Similar to the knee, it is best to immobilize the leg with a slight amount of flexion. Care should be taken to also immobilize the ipsilateral knee and ankle, as the long bones of the leg play an important role in stabilizing the adjacent joints. Compartment syndrome is once again a concern, occurring in 8.1% of tibial shaft fractures.",
        "Anatomy, fractures, and dislocations - Ankle and foot injuries": "When splinting ankle or foot injuries, consider pillow splints, air splints, or any other method that avoids pressure on the bony prominences. As with knee dislocations, if patient transport is to be significantly prolonged, properly trained and authorized prehospital personnel may consider reducing dislocated ankle joints that show signs of distal neurovascular compromise. Many foot and ankle injuries can be subtle and difficult to identify solely on clinical exam, but may be at risk for long-term complications if not evaluated early. To aid in triage of these patients, criteria such as the Ottawa decision rules have been developed to help ED providers determine the need for radiographs. However, such methods have not been validated in the prehospital setting. Without a validated method to rule out severe injury in the field, every effort should be made to transport these patients for further evaluation.",
        "Anatomy, fractures, and dislocations - Spine": "Injuries of the bony spine and spinal column are of concern in patients with multiple system trauma. The cervical spine is the most commonly injured area of the spine, followed by the thoracolumbar spine, lumbar, and thoracic spine, respectively. The incidence of cervical spine fractures in trauma has been estimated to be approximately 4%. However, the incidence of cervical spine injuries is higher (5\u201310%) in patients with head trauma or trauma above the clavicles. While the overall incidence of concomitant spinal cord injuries in all blunt trauma has been estimated to be less than 2%, it is the possibility of severe neurological impairment, including paralysis, lasting disability, or death that raises the level of concern and caution in the prehospital and acute care environment. Patients with vertebral spine or spinal cord injury can present with a variety of symptoms, from obvious paralysis to subtle neurological deficits or simply neck or back pain. The primary trauma survey may reveal clues to high cervical spine trauma. For example, patients with high cervical injuries may have impairment of the phrenic nerve, presenting with abnormal breathing or respiratory failure that can rapidly progress to death. Neurogenic shock due to impairment of the autonomic pathways presents with hypotension refractory to fluids and is often accompanied by bradycardia. Assessment of neurological disability may further raise suspicion of severe vertebral column injury. Patients with diminished sensorium have higher potential for harboring occult spinal cord trauma. A careful secondary survey should include a more thorough assessment of neurological status including motor and sensory testing. Further, prehospital providers should be alert for neurological symptoms indicative of central cord, anterior cord, and Brown-S\u00e9quard syndromes. The most common of these, central cord syndrome, occurs frequently in the elderly and classically presents with bilateral weakness, most severe in the distal upper extremities. Spinal injury should be suspected in any patient with any of the following findings. \u2022 Evidence of multiple traumatic injuries \u2022 Focal neurological symptoms such as weakness or numbness \u2022 Neck pain, back pain, or midline spine tenderness \u2022 Head injuries with significant mechanism AND altered mental status or evidence of significant intoxication \u2022 Distracting painful injuries in the setting of a suspicious mechanism Maintenance of neutral immobilization of the spine is the standard of care for any patient with suspected spinal injury. Two large, multicenter studies were conducted to explore predictors for safely clearing patients from spinal immobilization without radiographic imaging. However, it is important to note that these studies were not conducted in the prehospital setting. Additionally, each study asked the question whether or not to image the spine prior to clearing spinal immobilization, not whether to immobilize the spine during initial assessment. The most common technique for spinal immobilization includes placing the patient in a hard cervical collar and on a backboard. Once immobilization is initiated, the average amount of time patients spend on a backboard has been estimated to be over 1 hour. Prolonged use of a rigid backboard is associated with several complications such as pain and pressure ulcers as well as respiratory compromise and aspiration events. Additionally, there are several special circumstances of prehospital care, such as wilderness or search and rescue settings, in which total spinal immobilization carries substantial risks of injury to the first responders and is therefore used more judiciously than in standard practice. Given the range of significant complications associated with full spinal immobilization, there is growing interest in the prehospital and trauma literature regarding the utility of limited use of both full spine and cervical spine immobilization. There is increasing utilization of selective spinal immobilization policies among EMS systems. Some systems have examined the outcomes associated with these policies, with promising results indicating that such policies could be implemented safely in the prehospital setting. More research should be conducted to validate these preliminary studies and to create standardized guidelines for selective immobilization policies.",
        "Splinting": "Indications and basic technique Splinting is the mainstay of emergency immobilization of an injured extremity. Whether the injury is a fracture, dislocation, or sprain, immobilization in the position of comfort will help to reduce pain and chance of further injury. Other indications for splinting include reduction of hemorrhage and maintenance of alignment after reduction of a fracture or dislocation. The basic technique for splinting an injured extremity includes protecting the skin and soft tissue, applying a rigid material to immobilize the painful extremity, and securing the rigid material with a flexible material. While immobilization is essential, a splint should also not be applied tightly or circumferentially to the limb, in order to avoid neurovascular compression and compromise. The general rule of thumb is to leave at least one surface of a limb exposed to allow for continued swelling and to prevent complications.",
        "Splinting materials": "There are many commercial materials made of fiberglass or other durable components. These are primarily used in the ED or wilderness settings for longer term splinting. In the prehospital setting, where transport time is limited to generally less than 1 hour, and patient function and mobility are also limited, temporary materials such as cardboard secured by tape will provide sufficient immobilization and pain control. In austere settings, such as the wilderness or during a disaster response, non-traditional items can easily be repurposed to create a variety of splints or slings. For example, a large sheet or piece of clothing can be tied tightly as a pelvic binder. Hiking backpacks with a hard frame can serve as a partial backboard. Any large stick can be fastened to an extremity with tape or clothing for immobilization. Even prefabricated extremity splints (e.g. fiberglass) can be fashioned into effective, temporary cervical collars. Additionally, larger water bottles or jugs, when filled with water and fastened with rope, can provide the weighted component for a makeshift traction splint.",
        "Traction splints": "Prehospital use of traction devices for orthopedic trauma has been considered standard treatment of femoral shaft fractures. Commercial traction splints are considered required ambulance equipment by the American College of Surgeons, the American College of Emergency Physicians, the National Association of EMS Physicians, the Emergency Medical Services for Children Program, and the American Academy of Pediatrics. These recommendations posit that traction reduces pain and limits further blood loss, neurovascular damage, or soft tissue injury. However, there are downsides to prehospital traction splinting. Proper splint application takes two trained providers approximately 5\u20136 minutes to perform, contributing to EMS on-scene delays. Case studies have identified episodes of transient peroneal nerve palsies, compartment syndrome, urethral injury, pressure ulcers, and distal ischemia as a result of prolonged use of EMS traction devices. Further research has demonstrated suboptimal rates of proper splint application, much of which is attributed to the infrequency of its usage. Additionally, a Cochrane review found no benefit or significant analgesia related to preoperative hip traction. Further research is needed to better guide prehospital usage of these devices.",
        "Reductions with (and without) medications": "Field reduction versus definitive care The decision to allow field reductions of extremity fractures and dislocations is specific to the individual EMS system and each clinical scenario. There are widely accepted indications for one attempt at gentle reduction, which include distal neurovascular deficit or severe angulation. However, even these should generally be deferred if anticipated transport time is minimal (e.g. less than 10 minutes). System-specific variations in protocol should be considered for regions with large rural areas and extended transport times. Further, programs that regularly staff large sporting events may provide additional training to their providers that could allow for more aggressive field reduction techniques. When considering implementation of such protocols, availability of both on-scene supervisory personnel (e.g. EMS physician or sports medicine physician) and analgesia should be considered. There are good reasons not to allow field reductions except for the most critical circumstances (e.g. pulse deficit), which include converting a dislocation to a fracture-dislocation, causing further neurovascular compromise, or converting a closed fracture to an open one. Without prerduction films, there is no proof that a fracture preceded a reduction attempt. If a reduction is performed, the extremity should be splinted immediately after in the position of function, distal neurovascular status reassessed, and the patient should always be transported to the emergency department.",
        "Special considerations: partial or complete amputations and neurovascular injuries": "Emergency medical services providers are often the first medical personnel to encounter a patient suffering from a traumatic amputation and must be prepared to care for the amputated part as well as the patient. Once priorities such as bleeding control are addressed through either direct pressure or a tourniquet, attention should be turned to recovering and preserving the amputated part in addition to obtaining a thorough history that includes time of amputation, mechanism of injury, and the patient\u2019s handedness and occupation. EMS providers should not prognosticate likelihood of replantation. The stump can be gently cleaned of debris and gross contamination with sterile saline and then covered with saline moistened sterile gauze. The blood vessels of the stump should not be clamped, nor should the stump be manually debrided. An underlying fracture should be assumed, and the extremity should be splinted as such; this is particularly important in the setting of a partial amputation. Efforts should be made by the EMS crew on scene to locate the amputated part, and if the patient is not stable enough to await locating it, then another responder should be instructed to locate, store, and transport it to the hospital urgently. The amputated part should be wrapped in a saline moistened gauze pad and placed in a plastic bag, which then should be placed in a container of ice. The goal temperature is 4\u00b0C and care should be taken to not freeze the part. The part should not be placed directly on ice or be immersed in saline. The patient should be transferred urgently to a replantation-capable hospital, if available. If the patient meets major trauma criteria and the trauma center is not a replantation center, the patient should preferentially go to the trauma center.",
        "Conclusion": "Orthopedic injuries commonly present in the prehospital setting. EMS physicians, providers, and systems must be prepared to evaluate and treat these injuries appropriately. EMS physicians can provide a benefit to their systems by understanding the current evidence and best practices."
    },
    {
        "Introduction": "Although severe electrical injuries are relatively uncommon, the true incidence remains unknown. Many electrocution victims fall from heights, present with dysrhythmias, or are simply found dead; the significance, and even the occurrence, of an electric shock may be unknown. Electrical injuries tend to follow a bimodal age distribution. The first peak occurs in toddlers, who generally sustain electrical injuries from household electrical outlets and cords. The second peak occurs in adults who work with or around electricity for a living, such as miners, construction workers, and electrical utility workers. The National Electronic Injury Surveillance System from the Consumer Product Safety Commission estimates that emergency departments treated 5,500\u20136,500 patients annually for product-related electrical shocks from 1992 to 2012. The majority of these incidents were minor, resulting in emergency department evaluation and subsequent discharge. Most estimates place the annual death rate from electrical injury at 1,000\u20131,500 per year, with more than 60% occurring in adults 15\u201340 years of age. Electrocutions at home account for more than 200 deaths per year and are mostly associated with malfunctioning or misused consumer products. As far as occupational exposure is concerned, according to the Electrical Safety Foundation International, there was an average of approximately 280 fatal electrical injuries per year in all industries from 1992 to 2008; one in 10,000 electrical utility workers in the United States dies from electrical injuries.",
        "Basic concepts and pathophysiology": "Electricity, a flow of electrons across a potential gradient from higher to lower concentration, requires both a complete path, called a circuit, to create continuous flow and a potential difference, measured in volts (V), to drive the electrons through the circuit. The volume of electrons flowing along this gradient is the current, measured in amperes (A). Resistance is the impedance to flow of the electrons and is measured in ohms (\u03a9). In direct current (DC), electrons flow constantly in one direction across the voltage potential. Batteries are a common source of DC current, and high-voltage DC current is commonly used as a means for the bulk transmission of electrical power over long distances. Alternating current (AC) results when the direction of electron flow changes rapidly in a cyclic fashion. In the United States, standard household current is AC flowing at 60 cycles per second (Hz) and 110 V. In much of the rest of the world the standard household current is 220\u2013240 V flowing at 50 Hz. Low voltage has been arbitrarily defined as less than 1,000 volts. As a general rule, high voltage is associated with greater morbidity and mortality, although fatal injury can occur with low voltage as well. Six factors determine the outcome of human contact with electrical current: voltage, type of current, amount of current, resistance, pathway of the current, and duration of contact. In many cases, the magnitude of only a few of these factors is known. At the same voltage, AC exposure is considered to be about three times more dangerous than DC exposure. The differences in the two types of current have practical significance only at low voltages; at high voltages both currents have similar effects. AC current is more likely to produce explosive exit wounds, while DC current tends to produce discreet exit wounds. AC current is also more likely to cause muscular tetany than DC current. However, high-voltage contacts to both AC and DC current can produce a single violent skeletal muscle contraction, leading to the person appearing to be \u201cthrown\u201d from a voltage source. The physical effects of different amounts of current vary. A narrow range exists between the threshold of current perception (0.2\u20130.4 mA) and the \u201clet-go current\u201d (6\u20139 mA). The let-go current is the level above which muscular tetany prevents release of subject\u2019s grip on the current source. When AC current flows through the arm, even at the standard household frequency of 50\u201360 Hz, flexor tetany of the fingers and forearm can overpower the extensors. If the hand and fingers are properly positioned, the hand will grasp the conductor more tightly, leading to extended contact with the power source. However, current flow through the trunk and legs may cause opisthotonic postures and leg movements if the person has not grasped the contact tightly. Thoracic tetany is also possible and can occur at levels just above the let-go current, usually at 20\u201350 mA, resulting in respiratory arrest. Ventricular fibrillation (VF) usually occurs at 50\u2013100 mA. Electrocution causes injury in several ways. As electrical current is conducted through a material, resistance to that flow results in dissipation of both energy and heat, leading to tissue damage from direct heating. The amount of heat produced during the flow of current can be predicted using Joule's First Law, Q=I\u00b2Rt, where Q is the amount of heat generated, I is the current flowing through a conductor, R is the amount of electrical resistance, and t is the time of exposure. Using Ohm's Law, I=V/R, the relationship between voltage and heat generation can be derived as Q=V\u00b2t/R. Therefore, if resistance and other factors remain constant, the heat from current flow through tissue increases proportionately to the duration of current flow, the square of the current intensity, and the square of the voltage differential. This conversion of electrical energy to thermal energy can result in massive external and internal burns. In addition, electroporation, defined as the creation of pores in cell membranes by means of electrical current, can be caused by electrical charges insufficient to produce thermal damage but strong enough to cause protein configuration changes that threaten cell wall integrity and cellular function. Finally, muscle contractions or falling can result in blunt mechanical injury from exposure to high voltage. Because electricity requires a complete circuit for continuous flow, the path of electricity flow determines the tissues at risk, the type of injury, and the degree of conversion of electrical energy to heat. For example, current passing through the thorax might cause arrhythmias, direct myocardial damage, or respiratory arrest whereas cerebral current could cause seizures or motor paralysis. Nerves, blood vessels, mucous membranes, and muscles tend to have the least resistance because of their high concentration of electrolytes. The tissues that have the highest resistance to electricity tend to increase in temperature and coagulate. In particular, bone, which has a very high resistance to electrical current, tends to generate a significant amount of heat and often causes damage to nearby muscles. Skin can have a wide range of resistance to electricity, with dry skin having a higher resistance than moist skin. As a result, a patient with dry skin may have extensive superficial tissue damage but more limited conduction of potentially harmful current to deeper structures. On the contrary, wet skin (e.g., electrocution of a person in a bathtub or swimming pool) offers almost no resistance at all, thus generating the maximal intensity of current that the voltage can generate.",
        "Evaluation and treatment - Scene safety": "Scene safety is of critical importance at the site of an electrical injury. High-voltage power lines are almost never insulated but may appear insulated from atmospheric contaminants deposited on the lines over time. A rescuer standing on the ground touching any part of a vehicle that is in contact with a live power line is likely to be killed or seriously injured. In fact, electrocution can occur from ground current simply by walking too close to a downed power line. A common error is establishing a safety perimeter that is too small. The recommended isolation distance is one full span between the adjacent utility poles or towers in all directions from a break in the wire or from the point of contact with the ground. At a minimum, personnel should stay at least 3\u20139 m (10\u201330 ft) from downed power lines until the utility company unequivocally confirms that power to the lines is off. Electrical shock is not prevented by the rescuer wearing rubber gloves and boots unless they are specifically designed for the voltage present. The equipment must also have been recently tested for insulation integrity. A microscopic hole in a glove can result in an explosive injury to the hand because thousands of volts from the circuit concentrate at the hole to enter the glove. Ideally, it is best to turn off the source of electricity before contact with the victim. Some sources suggest using a non-conductive material, such as a broom handle, to attempt to remove a victim from electrical contact. This should be done only with extreme caution because when voltages are above approximately 600 V, even dry wood may conduct significant amounts of electric current, presenting danger to the rescuer. The EMS physician must be aware of other hazards at scenes of downed power lines. When voltage is reapplied to downed lines as circuit breakers reset, the lines may physically \u201cjump\u201d forcefully. In addition, although the metal cables that support telephone and power poles are normally grounded, they may become energized if they break or disconnect from an attachment and make contact with a nearby power line.",
        "Evaluation and treatment  - Management": "Cardiac arrhythmia and cardiac arrest are the most common causes of death in electrocution. There are several established and theoretical mechanisms for this: accommodation of the ventricular effective refractory period, asystole from direct current, direct induction of VF, induction of an intermediate ventricular tachycardia, induction of VF from long-term, high-rate cardiac capture, lowering the VF threshold through ischemia, respiratory arrest with secondary cardiac arrest, shock on cardiac T-wave. It is classically taught that AC current is more likely to cause VF, whereas DC current is more likely to cause asystole. Evidence for this is lacking. Cardiac monitoring is essential in patients who have suffered significant electrical injuries. Almost 50% of these patients exhibit electrocardiographic changes or rhythm disturbances. The most common electrocardiographic alterations are sinus tachycardia and non-specific ST-T-wave changes, which usually correct with time. In fact, if the patient's overall clinical condition is good and he or she has a normal ECG at the time of admission to the ED, the probability of observing any delayed serious dysrhythmia is unlikely. Because most dysrhythmias are transient, therapeutic interventions are rarely needed. Sometimes an injury pattern mimicking infarction may be seen on the ECG; such patterns are generally due to direct myocardial injury and not coronary thrombosis. The difficulty is identifying the existence of new myocardial damage and determining its physiological significance. Cardiopulmonary resuscitation should be initiated as soon as safely possible for victims of electric shock-induced arrest. For line workers, coworkers are trained to begin rescue breathing while still on utility power poles. As soon as the victim is lowered to the ground, chest compressions can be started if the patient is in cardiac as well as respiratory arrest. Because many victims are young and have no prior cardiovascular disease, resuscitation efforts should be aggressive. It is often not possible to predict the outcome of attempted resuscitation based on age and initial rhythm in electric shock-induced cardiac arrest. Normal BLS or ALS resuscitation protocols should be used, keeping in mind any necessary adjustments for rescuer safety and patient access. Once cardiac dysrhythmias and respiratory arrest are addressed, patients with electrical injury should be evaluated as trauma patients, treating any blunt injuries and caring for burns. Rescuers should assume that victims of electrical trauma have multiple traumatic injuries. Falls, being thrown from the electrical source by an intense muscular contraction, or blast effect from explosive forces that may occur with electric flashes can cause significant secondary blunt trauma. In addition, fractures and joint dislocations can be caused directly by forceful muscle contractions from an electric current. Therefore, in addition to cardiac monitoring and measurement of oxygen saturation, intravenous access and evaluation of the need for in-line immobilization of the spine should be implemented after the primary survey is completed. The primary electrical injury is the burn. There are two general patterns: surface burns and internal current flow. Appropriate burn care should be instituted for external burns. Constricting rings and other jewelry should be removed from all extremities whether or not injury is visualized. Patients with burns from high-voltage electricity should be taken to a trauma center. Because visible cutaneous damage generally underestimates internal damage, fluid requirements may exceed prediction using standard thermal burn injury formulas such as the Parkland formula. Most sources advise that an initial fluid volume of 20\u201340 mL/kg over the first hour is appropriate for a typical patient with a significant electrical injury. Further fluid administration will be guided by continued clinical and hemodynamic assessment.",
        "Lightning injury": "Lightning is a unidirectional cloud-to-ground current resulting from static charges that develop when a cold high pressure front moves over a warm moist low pressure area. It is neither a direct nor an alternating form of current. Although lightning can release greater than 1,000,000 V of energy, generate currents greater than 200,000 A, and reach temperatures as high as 50,000\u00b0F, the actual amount of energy delivered may be less than that typical of high-voltage injuries because its duration is as short as a few milliseconds. In the United States, lightning kills approximately 80\u201390 people per year, although 70% of lightning strikes are not fatal. Because people tend to seek shelter from lightning storms together, 30% of lightning strikes involve more than one patient. Lightning strikes tend to result in five basic mechanisms of injury. Direct strike. A direct strike is more likely to hit a person who is in the open and unable to find shelter. This type of lightning strike is usually fatal. Splash injury. This occurs when lightning strikes an object, such as a tree or building, or another person, and the current \u201csplashes\u201d to a victim standing nearby. Current can also splash to a victim indoors via plumbing or telephone wires. Contact injury. This occurs when the victim is in physical contact with an object or a person directly struck or splashed by lightning. Step voltage/ground current injury. When lightning hits the ground, the current spreads outward in a radial pattern. Because the human body offers less resistance to electrical current than does the ground, the current will preferentially travel through the body (e.g. up one leg and down the other) between the body\u2019s two points of ground contact. Blunt trauma. Victims of lightning strike may be thrown by the concussive forces of the shockwave created by the lightning. A lightning strike can also cause significant opisthotonic muscle contractions, which may lead to fractures or other trauma. The first priority in responding to a lightning strike is scene safety. Contrary to popular myth, lightning can, and often does, strike the same place twice. Although lightning strikes may cause multisystem injuries, the most common cause of death is immediate cardiorespiratory arrest. Unlike the typical trauma patient, however, lightning victims have significant resuscitation potential, which gives rise to the EMS lightning triage mantra. The cardiac effects of lightning injury can include anything from non-fatal arrhythmias, including bradycardia, tachycardia, premature ventricular contractions, ventricular tachycardia, and atrial fibrillation, to myocardial depolarization and asystole. Lightning may also cause paralysis of the medullary respiratory center, leading to prolonged respiratory arrest. With early and sustained respiratory support by EMS providers, many patients have excellent prognoses. Although lightning produces significant heat and voltage, severe burns are uncommon because of the short duration of exposure. Compared with high-voltage electrical injuries, burn care and aggressive volume resuscitation for deep tissue injury are less important considerations. Full-thickness entry and exit burns are occasionally present, but deep burns and tissue damage are less common than in typical high-voltage electrical injury. In many victims struck during rain, the low resistance of wet skin results in a \u201cflashover\u201d effect, decreasing the current transit through the body and thus decreasing the risk of severe internal injury. Flashover occurs when the lightning strikes a victim, and the current flashes over the outside of the body along the wet skin surface, vaporizing the moisture and causing superficial burns \u2013 and often blasting shoes and clothing off the victim\u2019s body. Linear and punctate burns may be seen along the paths of sweat or rainwater accumulation. Full-thickness burns may occur at sites of contact with metal objects, such as jewelry. Lichtenberg figures, or feathering burns, are pathognomonic of lightning injury, but are not true burns. They are thought to be the result of electron showers that cause extravasation of red blood cells into the superficial skin layers along the current lines of the flashover. Potential neurological effects of lightning injury include loss of consciousness, confusion, memory loss, seizures, persistent headaches, paralysis, mood disorders, chronic pain syndromes, cerebellar dysfunction, and peripheral neuropathies. Hearing loss may result from sensorineural damage or from direct otological injury to the tympanic membrane or middle ear. Keraunoparalysis, or \u201clightning paraplegia,\u201d is an immediate effect of lightning injury and consists of paralysis of the limbs with pallor, cool temperature, and absent pulses. It is not actually a neurological phenomenon, but rather the result of severe arterial vasospasm from catecholamine release. It usually resolves within hours, but it can create a difficult and misleading initial patient assessment. Other considerations in the lightning victim include blunt trauma, either from being thrown or from significant muscle contractions. The lightning victim may also have been struck by falling tree limbs or building debris. The appropriate precautions, including proper spinal immobilization, must be observed. Because deep tissue damage is less common in lightning strike victims than in victims of high-voltage electrical injury, myoglobinuria and acute renal failure are seen less frequently. However, acute renal failure has been reported in 3\u201315% of victims of major lightning strikes, so appropriate fluid resuscitation should be initiated in the pre-hospital setting. Rescuers should care for lightning strike victims using standard BLS and ALS principles but should amend multicasualty triage priorities, providing initial care to the apparently dead victims first. Victims who do not suffer immediate cardiac or respiratory arrest are unlikely to die from their injuries. Bystander CPR should be strongly encouraged. Dilated or non-reactive pupils do not indicate brain death in the lightning strike victim and therefore should not be used to determine prognosis. Patients should receive cardiac and pulse oximetry monitoring during transport, and trauma precautions, including spinal immobilization, must be observed. Because the extent of injury may not be readily apparent based on external signs, all lightning strike patients require transport for hospital evaluation. Any lightning strike victim with obvious injuries such as long bone fractures, external burns, respiratory compromise, cardiac arrhythmias, hypotension, or altered mental status should be transported to a trauma or burn center for evaluation.",
        "Conclusion": "All responders, including the EMS physician, must be familiar with the potential hazards that may be present at an electrical injury scene. The outcome of human contact with electrical current is largely determined by voltage, type, and amount of current, pathway of the current, resistance, and duration of contact. Immediate mortality is generally related to cardiac or respiratory system dysfunction. Because of this, triage schema may need to be altered at the scene of a mass casualty electrical incident. Later sequelae are typically related to burns or other traumatic injuries and often require trauma center or burn center care. Understanding the nature of electricity can help the EMS physician stay safe, predict injury patterns, and more effectively care for patients."
    },
    {
        "Introduction": "Animal bites are estimated to account for 1 million physician visits each year and for 1% of emergency department (ED) visits. The actual number of animal-related injuries is impossible to calculate because many injuries go unreported. The infrequent nature of animal-related calls, coupled with the excitement and emotion often found on scene, can lead to poor provider judgment or errors in proper care. This chapter focuses on prehospital management of animal bites, stings, and envenomations and reviews injuries likely to be encountered, with specific prehospital treatments and interventions where appropriate.",
        "Animal bites - Scene safety and preplanning": "As with any EMS response, scene safety is a primary concern. When responding to a call involving animals, all personnel should prevent interaction with the offending animal. Prehospital providers and medical directors should be aware of animal control resources available in their coverage areas. Protocols for responding to animal-related calls should include these resources when appropriate. The primary responsibility of EMS personnel is for their own safety and the safety of the patient. Providers should not be primarily responsible for dealing with the animals. While identification of the offending animal may be helpful for treatment, attempting to catch or quarantine the animal exposes the EMS provider to undue risk. For related reasons, transportation of animals, dead or alive, to the hospital for identification is not advised.",
        "Animal bites - Refusal concerns": "As many animal-related injuries initially appear benign, both patients and providers often underestimate their potential seriousness, resulting in inappropriate refusal of treatment or transport. Agencies should consider mandatory medical oversight contact for refusal of care in animal encounter situations, as serious risks exist.",
        "Animal-specific concerns - Mammals": "Mammals Domesticated animals account for the vast majority of mammalian bite wounds, with dogs and cats representing 93\u201396% of mammalian bites. Bites by both types of animals occur most frequently to the upper extremity, followed by the lower extremity, and finally the face and neck. Acutely lethal wounds tend to occur in young children. Children are often familiar with the offending animal and are more prone to attacks to the face and neck. In both cats and dogs, unique oral flora contributes to considerable infection risk. While most wounds do not become infected, those that do often require in-hospital therapy and potential operative management. Two-thirds of hand bites in one study required hospitalization for IV antibiotics, and one-third required at least one surgical procedure. Systemic complications including endocarditis, meningitis, brain abscess, and sepsis must also be considered by providers and medical directors when determining protocols and transport decisions. Human bites carry risks of complications similar to those of other mammalian bites. Hand wounds involving the metacarpal-phalangeal joint and overlying extensor tendons are often \u201cfight bites\u201d (injuries to the hand from striking teeth during an altercation) and are especially prone to infection. More than 30% of fight bites become infected, resulting in decreased functional capacity. Fight bites often coincide with intoxication and/or criminal activity that may act as a barrier to prehospital care through reluctance to disclose the true mechanism, patient refusal, or law enforcement custody. Very few poisonous mammals exist in North America. Only the short-tailed shrew, found in central and eastern sections of North America, poses a toxic threat. Several non-indigenous mammals have poisonous reputations. The shrew-like solenodon, found in Central America, induces toxins in its saliva through grooved incisors. The platypus, found in Australia, has venomous glands introduced by spurs at the base of its hind feet. In all of these animals, the toxins serve to kill prey and defend from predators. Bites to humans result in unusually painful wounds with local edema, but typically lack serious or systemic effects. Accounting for less than 10% of animal bites, attacks by wild or undomesticated mammalians are rare and usually require only supportive care and basic wound management in the prehospital setting. In general, most bite victims should be transported to the emergency department for wound evaluation, tetanus shots, and possibly antibiotics.",
        "Animal-specific concerns - Rabies": "Mammalian bites carry the unique risk of rabies virus transmission which is almost universally fatal. Current Centers for Disease Control and Prevention (CDC) guidelines recommend postexposure prophylaxis (PEP) including immunoglobulin administration and vaccination series for high-risk bites in vaccine-naive individuals, and a modified vaccination series for those previously vaccinated. Bites from skunks, foxes, raccoons, bats, and some other carnivorous animals are considered at risk and should receive PEP promptly. For domestic animals that appear healthy and can be quarantined for 10 days, PEP can be withheld pending development of symptoms. Patients with bites from other animals should be transported to the hospital so that the need for PEP can be determined. Bats require special consideration because rabies transmission has occurred outside of recognized bites. Although data are conflicting and perhaps viewed as controversial, PEP \u201ccan be considered for persons who were in the same room as the bat and who might be unaware that a bite or direct contact had occurred (e.g. a sleeping person awakens to find a bat in the room or an adult witnesses a bat in the room with a previously unattended child, mentally disabled person, or intoxicated person) and rabies cannot be ruled out by testing the bat.\u201d Thus, EMS providers should have a very low threshold to transport potential victims to the ED for evaluation whether an obvious bite exists or not.",
        "Reptiles - Venomous snakes": "Of the estimated 45,000 annual snake bites in the United States, roughly 8,000 are reportedly from venomous snakes. There are 25 venomous species of snakes in the United States. The majority of these are in the subfamily of Crotalids (rattlesnakes, cottonmouths, and copperheads), and the remainder in the Elapid subfamily (coral snake). This division also represents a difference in their respective toxins and clinical manifestations of envenomation. Crotalid venom is a primarily a hemotoxin (with some cytotoxic and neurotoxic properties) and produces symptoms ranging from local swelling and ecchymosis to systemic coagulopathy, altered consciousness, and shock. The constellation of effects begins within minutes and steadily progresses to its maximal extent over a number of hours (up to 24 hours with leg bites). Elapid envenomations can remain relatively asymptomatic for up to 12 hours and then manifest neurotoxicity ranging in severity from paresthesia to complete paralysis requiring ventilatory support. In either case, it is important to avoid underestimating bite severity based on initial patient assessment at the scene. Although \u201cdry bites\u201d occur with relative frequency, the lack of clinical swelling should not lead the provider to assume that no envenomation has occurred. A period of observation of varying lengths depending on the bite site is recommended by toxicologists and should prompt any and all patients with suspected bites to be transported to the emergency department for evaluation. Much of EMS provider education about snake bites should focus on dispelling common myths. Providers may encounter well-meaning citizens attempting to render \u201cfirst aid\u201d to snake bite victims. Cold therapy, arterial tourniquets, electricity (from TASERs or car batteries), incision of the wound, and suction (via commercially available device or oral) are popular lay therapies for snake bite that are without scientific backing and may lead to more local tissue damage. While some of the literature has suggested treatments such as compression immobilization, all of the major toxicological societies of North America advocate against this technique for US crotalid envenomations. Keeping the patient calm and immobilizing the affected extremity in a neutral position is the best course of action in the prehospital setting. Insufficient evidence exists for compression immobilization in hemodynamically unstable patients. Effectiveness of pressure immobilization has been suggested in the setting of Australian elapid snake bites and thus, as a corollary, compression immobilization for confirmed North American elapid envenomation may be considered for those with anticipated long transport times. Furthermore, if longer transport times are anticipated after elapid envenomation, EMS should be prepared to intervene on the airway and assist with ventilation. Routine use of antivenin therapy is not generally recommended in the prehospital setting, as it requires a significant amount of time and resources to prepare and administer. Adequate analgesia is a significant concern after crotalid envenomation. In the acute phase, toxicologists recommend the use of intravenous fentanyl as opposed to other opioids so as not to confuse the crotalid envenomation symptoms with morphine-induced histamine release, both of which can cause anaphylaxis, hypotension, and local swelling.",
        "Reptiles - Nonvenomous snakes": "The majority of snake bites in the US are from non-venomous species. Most of these snakes are in the Colubrid family and include the garter snake, hognose snake, banded water snake, rat snake, and parrot snake. Morbidity from these snakes is extremely rare. Transport to a hospital for observation and wound evaluation is recommended. Bites should be considered contaminated since they may contain broken teeth. Antibiotics are generally not necessary with the exception of retained teeth or significant soft tissue injury. Constrictors and pythons are commonly kept as pets and can have very forceful bites. Their teeth are brittle and prone to fracture with attempted extrication. X-rays to assess for retained teeth and tetanus prophylaxis should be considered and thus EMS should recommend transport to the ED for radiographic evaluation of these bites.",
        "Reptiles - Other reptiles": "Gila monsters and bearded lizards have venom in their saliva injected through grooved teeth and a strong and tenacious bite. Envenomation, however, is usually not lethal and most often causes only local inflammation and pain. Although rare, there have been reports of anaphylactic reactions as well as angioedema, hypotension, myocardial infarction, and coagulopathy. Other reptiles have been involved in fatal bite attacks and appropriate trauma care should be used for these wounds. Transport should be advised as these bites are prone to infection with uncommon forms of bacteria.",
        "Marine animals": "Marine animals that sting can cause serious pain and tissue damage. North American venomous marine vertebrates (i.e. stonefish, scorpionfish, lionfish, catfish, stingrays) carry heat-labile toxins that generally respond to heat therapy for toxin neutralization and pain reduction. Invertebrate marine animals (i.e. jellyfish) use tentacles or nematocysts to deploy their toxins. Previous recommendations include flooding the area with acetic acid (vinegar) and then scraping off the tentacles. More recent literature suggests that hot water and topical lidocaine may be more effective for symptom control and acetic acid may be more efficacious for bluebottle jellyfish stings. Gloves or forceps should be used to manually remove visible tentacle remnants. Other therapies are sourced in folklore, including the use of urine, sand, or meat tenderizer, all of which are inappropriate. Often, reimmersion in salt water improves pain. Prehospital personnel should not routinely remove impaled foreign bodies, such as sea urchin spines or stingray barbs, as the spines easily fracture and may require surgical debridement. ",
        "Insect bites and stings": "Butterflies, moths, and caterpillars The order Lepidoptera encompasses the families of butterflies, moths, and their larvae, caterpillars. In the United States, the puss caterpillar, flannel moth caterpillar, Io moth, and saddleback caterpillar can have toxic effects. The venom is transmitted via hollow spines, and clinical manifestations may include local pain, burning, swelling, vesicle formation, and, less commonly nausea, vomiting, seizures, and regional adenopathy. Treatment is symptomatic and supportive with antiemetics for nausea and vomiting and benzodiazepines for seizures.",
        "Hymenoptera": "Hymenoptera account for the majority of severe allergic responses and anaphylaxis in comparison with other insects. There are three families of Hymenoptera: Apidae (honeybees and bumblebees), Vespidae (yellowjackets, hornets, and wasps), and Formicidae (fire ants). About 1% of children and 3% of adults report severe systemic allergic reactions to Hymenoptera venom, and anaphylaxis does not require a previous exposure (or sting). Furthermore, if a person is allergic to one type of Hymenoptera, he or she is likely to be allergic to the others as well. Clinical manifestations of Hymenoptera envenomation range from local reaction to hypersensitivity reactions (including anaphylaxis), fever, rhabdomyolysis, acute renal failure, and death. Apis mellifera scutellata or \u201ckiller bees\u201d are an aggressive hybrid of the honeybee and have the same venom, but are prone to mass attack, thus increasing the risk of a severe reaction. \n\nFire ants are named after the burning pain and necrosis victims experience after exposure. Grabbing the skin with its mandibles, the fire ant injects venom from a stinger on its abdomen in a circular pattern an average of seven or eight times. Large areas of swelling develop that later turn into sterile pustules. Anaphylaxis is relatively common and occurs in up to 6% of those envenomated.\n\nAllergic reactions should be treated with antihistamines, albuterol, and/or intramuscular epinephrine, depending on the severity. Angioedema, stridor, and signs of upper airway obstruction are of particular concern and should be monitored closely. Cool compresses may help with local pain. Emesis and abdominal pain can be additional symptoms of anaphylaxis and EMS should have a low threshold to transport any of these patients to the hospital.",
        "Spiders": "There are three clinically significant species of spiders found in North America: the black widow, the brown recluse, and the hobo spider. Black widow spider bites are often quick and painless, but may be experienced as a pinprick sensation that quickly resolves. Calcium channel-mediated neurotransmitter release of acetylcholine and other excitatory neurotransmitters can result in extremely painful muscle spasm, hypertension, and diaphoresis in the hours following envenomation. Fatalities are rare and therapy should be supportive. Opioids for pain and benzodiazepines to aid in muscle relaxation and minimize hypertension may be considered in the field. Some controversy exists among experts about the use of black widow antivenin. EMS should transfer all suspected cases of widow bites to the ED for possible antivenin administration.\nBrown recluse and other recluse species are found in the Mississippi River valley and the surrounding states, south east, and south west. The bite has been associated with an evolving necrotic lesion; however, more severe systemic manifestations have been reported, termed \u201csystemic loxoscelism.\u201d Signs and symptoms of loxoscelism include fever, vomiting, rhabdomyolysis, hemolysis, disseminated intravascular coagulation, renal failure, and death. Appropriate clinical skepticism should be exercised given the frequency of misdiagnosis and conflicting reports of loxoscelism in areas where recluses are not endemic and the attribution of more common skin lesions, including folliculitis and abscess formation, to a \u201cspider bite.\u201d Regardless, transport to the ED for wound evaluation is recommended and intravenous fluids and antiemetics should be administered. The hobo spider, a European native, is found in the northwestern United States. It is reported to cause dermonecrotic lesions as well. These lesions can be associated with headache, visual impairment, nausea, vomiting, weakness, and lethargy. Regardless, as with the brown recluse, treatment is supportive and there are no specific prehospital therapies recommended. Fifty-four species of tarantula are known to habit the desert south west. Despite their size, their toxicity is relatively minor. New World tarantulas are equipped with urticating hairs they release in self-defense. Depending on the species and type of hairs, clinical manifestations range from local inflammation to severe respiratory inflammation and significant eye injury. Prehospital management includes removal of hairs with cellophane tape and irrigation of the eyes. Antihistamines and corticosteroids may be considered. Any patient with ocular complaints requires transport to the hospital for ophthalmological evaluation.",
        "Scorpions": "The only scorpion of toxicological importance endemic to the United States is Centruroides exilicauda (the bark scorpion). Scorpions envenomate by stinging with their tails and can cause significant morbidity, especially in children. The venom is a neurotoxin that opens sodium channels, causing catecholamine and acetylcholine release. A scorpion antivenom exists and is used for those with systemic neurotoxic symptoms. Prehospital treatment may consist of symptomatic treatment with opioids and benzodiazepines.",
        "Ticks": "Ticks are eight-legged arthropods that live off the blood of various animals. Accordingly, they are vectors for viral, bacterial, and parasitic diseases, including Rocky Mountain spotted fever, typhus, tularemia, Lyme disease, babesiosis, ehrlichiosis, Colorado tick fever, and tick-borne encephalitis. Certain North American species, namely the Lone Star tick, the American dog tick, and the Rocky Mountain wood tick, secrete venom capable of causing paralysis in a manner similar to botulinum toxin. Discussion of each of the various tick-borne illnesses is outside the scope of this chapter; however, prehospital providers should be aware that prophylactic therapy may be offered to patients with known tick bites and the curative therapy for tick paralysis is removal of the tick. Supportive therapy including close attention to airway and breathing is paramount in any patient with ascending motor paralysis from possible tick-related disease.",
        "Non-indigenous animals": "This chapter has focused on species found in North America. EMS physicians and providers should take the time to learn about non-indigenous animals in their area. There is not enough room to cover all harmful animals in this chapter and providers should look to other toxicological texts for more in-depth information. It is also important to recognize that exposure to non-indigenous animals can occur not only in zoos or known refuges, but in private collections or simply as pets. In the case of private collectors, the owner often is aware of the species as well as its clinical effects, but may be resistant to seeking medical care for fear of legal persecution or confiscation of his or her collection. Poison centers and zoos are the best resources to help find appropriate antivenins. High-quality supportive care should be the standard, with local public health and poison control authorities guiding specific therapy.",
        "Transport": "Emergency medical services providers should encourage transport to the hospital. Transport preference should be a facility with a toxicology service or access to a toxicology consultant. If this is not possible within a reasonable time frame, patients should be transported to a local tertiary care facility that has emergency, trauma, and surgical specialties readily available. Prehospital protocols should specify when to contact medical oversight about the use of aircraft for transport of patients to an appropriate facility.",
        "Conclusion": "Our environment presents unpredictable encounters with animal bites, stings, and envenomations. Education on animals found locally may help EMS providers feel more comfortable during a response. Providers and medical directors should remember that most care is supportive and symptomatic. Transport to an appropriate facility will give the patient the best chance of a good outcome."
    },
    {
        "Introduction": "A contemporary understanding of explosive injuries is essential for all out-of-hospital health care providers. Although most explosive injuries were previously encountered in austere and/or military environments, civilian attacks with explosive devices have now become more frequent due to the inexpensive nature and ease of access of explosive materials. In fact, the average number of bombings is five per day within the United States, with a total of 36,110 bombing incidents causing almost 700 deaths from 1983 through 2002. In the most recent explosive events on US soil in Boston, there were over 200 casualties. Newer explosive devices used in recent attacks have resulted in casualties with severe combined penetrating, blunt, and burn trauma. In addition to terrorist bombings, accidental industrial explosions are also common. Although arson has not typically been included in the terrorist's agenda, some explosive agents and materials used in attacks have flammable injury potential because terrorists typically aim their attacks at human beings directly. These explosive and burn types of injuries are not typically different from non-explosive burns; however, the severity and complexity of injury and/or number of burn patients are potentially greater in the former than in the latter. Burn injury and management will be discussed in Volume 1, Chapter 33.\n\nThe medical provider treating explosive trauma in the out-of-hospital environment is faced with many unique challenges. Some of these challenges include the possibility of multiple casualties, unsafe environment, lack of medical supplies, prolonged evacuation time and distance, and lack of sophisticated care that is the standard for trauma management in the urban environment. This chapter will cover the evaluation and treatment of explosive injuries in the out-of-hospital environment.",
        "Explosive devices": "Because of the current increased terrorist threat and occurrences in many countries, many types of explosive devices can now be purposefully or accidentally encountered by out-of-hospital personnel in the civilian environment. Multiple types of improvised and manufactured explosive devices exist and only a few will be discussed. Most accidental explosive injuries occur from handling or encountering mines, improvised explosive devices (IEDs), or unexploded ordnance (UXO), such as grenades and ammunition. In Afghanistan alone, the combined death and injury rate was 150\u2013300 per month from accidental UXO even before the US conflict. The most common, purposeful explosive injuries currently in combat operations are from IEDs, homemade devices that cause injury or death by using explosives alone or in combination with toxic chemicals, biological toxins, or radiological material. IEDs can use commercial or military explosives, homemade explosives, or military ordnance and can be found in varying sizes and containers, and with various functioning and delivery methods.",
        "Blast injury": "An explosion is caused by the rapid chemical conversion of a liquid or solid material into a gas with a resultant energy release. Low explosives (gunpowder) release energy slowly, by a process called deflagration. In contrast, high explosives release energy rapidly through a process called detonation, which involves the almost instantaneous transformation of the physical space occupied by original solid or liquid material into gases, filling the same volume within a few microseconds, thereby expanding under extremely high pressure. The highly pressurized gases compress the surrounding environment, generating a pressure pulse that is Propagated as a blast wave. As a blast wave passes through the body, it causes damage by several different mechanisms. Patients injured from explosions usually suffer from a combination of blast, blunt, penetrating, and burn injuries. Injuries from explosives are divided up into categories",
        "Primary blast injury": "As the blast wave passes through tissues of different density, disruption occurs and small particles of tissue and liquids are thrown into the air space. This phenomenon is called spall. Not surprisingly, the injuries from this pressure wave tend to occur at sites of a gas/tissue interface (e.g. sinus, lung, middle ear, or bowel). Traumatic brain injury can also occur without other signs of head injury.",
        "Secondary blast injury": "Injury from projectiles or secondary blast injury represents the most common cause of trauma from explosive events and causes the most significant mortality and morbidity when the victim(s) survives the primary injury. Most improvised explosive devices have projectiles packed around them (e.g. nails, ball bearings) to increase the injury potential from secondary blast injury.",
        "Tertiary blast injury": "Tertiary blast injury results when victims are displaced by the blast wave and they become projectiles themselves. The resulting injuries may be severe and include a mix of blunt and penetrating trauma. In addition, structural collapse may contribute to the injuries under tertiary blast injury.",
        "Quaternary blast injury": "These are related to the thermal effect of the blast and exacerbation of existing medical conditions. Many primary, secondary, and tertiary blast injuries will be complicated by quaternary injury. Extensive burns, as well as exacerbation of medical conditions, may be related to explosions. The most common medical conditions affected are respiratory diseases such as asthma or chronic obstructive pulmonary disease; however, many other medical conditions may be exacerbated by explosive events.",
        "Quinary blast injury": "Quinary injury is related to the intentional addition of radiological, chemical, or biological compounds to the explosive device with the intent of exposing victims to the additional hazard. This has included the use of suicide bombers who are infected with infectious diseases such as human immunodeficiency virus or hepatitis. The possibility of biological contamination creates issues regarding postexposure prophylaxis (PEP). Recommendations for PEP by the Centers for Disease Control are summarized in Table 32.2. To determine appropriate actions in response to evaluation of casualties of bombings or other mass casualty events, health care providers should:\n1 assess individual exposure risk by categorizing the patient into one of three exposure risk categories that are numbered sequentially:\n\u2022 Category 1: penetrating injuries or non-intact skin exposures\n\u2022 Category 2: mucous membrane exposures\n\u2022 Category 3: superficial intact skin exposures without mucous membrane\n2 identify the appropriate risk category and pathogen-specific management recommendation(s)\n3 determine the appropriate action to take in response to management recommendations.\n\nRadiological contamination from \u201cdirty bombs\u201d has received a great deal of press attention. Screening for radiation should be considered for all potential terrorist bombings. If there is radiological contamination, although care of injuries takes precedence, patients should undergo appropriate decontamination and health care providers should wear appropriate personal protective equipment to avoid cross-contamination to themselves or others. These precautions also apply to potential chemical contamination.",
        "Prehospital resuscitation and treatment": "Specific recommendations for tactical, military, and mass casualty scenarios will be discussed in other chapters of this text. However, some of these treatment principles do overlap. In explosive environments, there is a significant increase in the number of penetrating traumatic injuries (e.g. gunshot, fragmentary, and blast propellant wounds). Because of the increased complexity and number of casualties and the possibility that civilian providers may be exposed to such, additional training and knowledge of the Tactical Combat Casualty Care (TCCC) guidelines are important for prehospital personnel. Although advanced trauma life support may be applicable to the emergency department management of trauma patients in both civilian and military hospitals, it was not created for out-of-hospital medicine. The three goals of TCCC are to treat the casualty, to prevent additional casualties, and to complete the mission, while maintaining provider safety.\n\nPatients exposed to indoor blast are at risk of overpressure primary pulmonary blast injury. Patients with primary pulmonary blast lung are also at risk for arterial gas embolism (AGE). Gas from the damaged alveolus can pass directly into the pulmonary veins and enter the systemic circulation, leading to neurological or pulmonary compromise. Patients with potential pulmonary blast injury who rapidly decompensate after intubation should be considered to have developed AGE. Additionally, in patients with primary pulmonary blast injury, the pulmonary injury may be worsened by overaggressive fluid resuscitation. This must be balanced against the fluid needs for trauma and burn management.\n\nCervical spine (c-spine) injury must be considered in patients in explosive events. Tertiary injury and structural collapse are common mechanisms for injury. For rescuers, the risk of structural collapse and potential for secondary devices or other threats such as sniper fire must be weighed against the benefits of c-spine control. For patients with only penetrating injury, numerous studies have shown that high-velocity penetrating wounds do not result in occult spinal injury. If there is no clinical sign of spinal injury at the time of the initial insult, c-spine precautions do not need to be maintained in alert and awake patients. For patients with blunt injury mechanisms, c-spine control should be performed when safe for the rescuer and patient.\n\nIn a mass casualty incident with blast and burn injuries, CPR should be withheld unless the injuries are the result of an electrical incident. An effort to identify and treat reversible causes (airway obstruction, tension pneumothorax, or hemorrhage) should be undertaken, after which the patient, if pulseless, may be declared dead based on local EMS protocol.",
        "Medical oversight": "Training Practicing effective medical care in an environment involved with explosives (i.e. tactical environment) requires prehospital personnel to be well educated, trained, and equipped. Integrated \u201cteam\u201d training allows the medical support members to understand their roles and to learn all aspects of tactical law enforcement operations and fundamentals on how to approach the tactical medical arena. Tactical competency-based guidelines have recently been published to guide the development of Tactical Emergency Medicine Support (TEMS) training curricula. A project has been initiated by the Centers for Disease Control and Prevention to develop a nationally standardized curriculum for tactical medicine training.\n\nThis project, using an expert panel and review of the scientific literature, refined the previously published outcome competencies and developed terminal and enabling training objectives to the competencies. In addition, training curricula have been established, such as the National Tactical Officers Association's Specialized Tactics for Operational Rescue and Medicine (STORM) for medics, operators, medical directors, and team commanders. These courses are based on the national TEMS curriculum and use the trainer methodology.",
        "Hazardous materials": "Incidents involving clandestine drug laboratories and weapons of mass destruction are also considerations in an explosive environment. Rapid decontamination must be taught and practiced by EMS teams because adequate decontamination is usually not available in the inner perimeter.",
        "Forensic science": "Basic knowledge of forensic science is important for recognition and preservation of evidentiary items. Documentation of wound and blood patterns should be done. All evidence should be collected appropriately and the chain of custody maintained.",
        "Medical threat assessment": "Medical threat assessment (MTA) is an important part of medical planning and should be integrated into operations involving response to explosive events. The MTA considers the potential medical threats that may confront the responders during EMS operations and develops the plan to mitigate and respond to the threats. Once the MTA is complete, a plan is then developed on the basis of the medical intelligence to address each possible situation, with the realization that the plan may change as the mission evolves.",
        "Preventive medicine and force health protection": "The maintenance of the EMS team's health is an important aspect of an explosive response program. Poor health has been shown to directly correlate with poor job performance and mission failure.",
        "Liability": "Because special operations lend themselves to high litigation and possible disability, EMS providers need to ensure that they have proper malpractice and disability coverage for special events.",
        "Conclusion": "Explosive injuries present a significant challenge for the medical provider. Explosives are inexpensive and easy to make and use. EMS and hospital providers need to be prepared to confront these events if they occur. Basic ATLS principles should be modified for the possibility of prolonged evacuation times to definitive medical care, as well as the limited availability of medical supplies. The basics, however, remain unchanged with airway control, restoration of effective breathing, and hemorrhage control being the highest priorities. Once the secondary survey is completed, care can be undertaken with minimal wound debridement, copious irrigation, prevention of hypothermia, and early administration of antibiotics and pain medications to decrease morbidity and mortality."
    },
    {
        "Epidemiology": "Drowning remains a leading cause of unintentional death and unintentional injury. The Centers for Disease Control (CDC) place the incidence of non-fatal drowning at between 4,000 and 7,000 cases per year. Fatalities range from 3,200 and 6,000 cases per year. The incidence of non-fatal drownings ranges from one to four times that of fatal drownings. Over 50% of all non-fatal drownings require hospitalization. Drowning and near drowning are the second most common unintentional injuries for ages 1\u20134 and 15\u201319. In infants less than 1 year old, most drownings occur in the bathtub. For children less than 4 years old, most drownings occur in private pools. For age greater than 15 years the predominant drowning locations include natural water settings such as beaches and lakes. Fatalities are higher for victims less than 4 years old. Compared with females, males have twice the rate of non-fatal and five times the rate of fatal drowning. Over half of adolescent and adult drownings involve alcohol or illicit substance use. Approximately 35% of persons who drown under the age of 20 are classified as accomplished swimmers. Preexisting medical conditions may play a role as well, as noted in children with seizures having a four-fold increase in risk compared to the general population. Drowning accidents involving children commonly result from lapses in adult supervision. In the majority of child drownings, the child was under the care of one or both parents and was \u201cout of sight\u201d for less than 5 minutes. While surveyed pool owners favor cardiopulmonary resuscitation (CPR) requirements, less than half of these households actually have a CPR-qualified individual. Of pool owners favoring isolation fencing around pools, only one-third had their pool fenced. The risk of drowning or near drowning is 3\u20134 times higher in unfenced than fenced pools. Epidemiological and public health data highlight the role of education, planning, and other community-level interventions in drowning prevention. Estimates of preventable drowning deaths are as high as 80%. Many EMS systems participate in drowning prevention efforts, such as education and water safety programs.",
        "Pathophysiology of drowning": "Drowning is commonly defined as suffocation and death as the result of submersion in a liquid environment. Historically, two types of drowning have been described: wet and dry. \u201cWet drowning\u201d is the aspiration of material such as water, sand, vomitus, etc. This material can lead to pulmonary edema, pneumonitis, and surfactant dysfunction, impairing gas exchange. \u201cDry drowning\u201d involves minimal aspiration; the inhaled liquid triggers laryngospasm, resulting in suffocation. Experts have questioned the mechanisms and clinical significance of this differentiation. Some postulate that decreasing level of consciousness and increasing hypoxia will eventual break any \u201cspasm,\u201d allowing liquid to enter the lungs. Submersion describes the airway opening beneath the surface of the liquid medium\u2013air interface, while immersion is the splashing of liquid in or about the airway. Classically, drowning begins as a period of panic and struggle, but in a minority of cases (for example, cervical trauma or seizure), this initial phase may not be present. Death from drowning ultimately results from suffocation, tissue hypoxia, and cardiac arrest. Successful resuscitation after a drowning-induced cardiac arrest is rare. Historically, drowning education materials have emphasized differences in fresh-water and salt-water drowning, citing the theoretical electrolyte and fluid shifts occurring with each situation. However, current practice downplays the importance of these differences. Some consideration of the water contaminants may be clinically important in the hospital setting, and the EMS insight into those scene variables may be helpful to hospital staff. Cerebral hypoxia plays a significant role in the functional recovery of the victim. Many drowning survivors suffer some permanent neurological damage, with up to 10% suffering severe lasting effects. The duration of hypoxia is correlated with submersion time and is an important determinant of recovery. Another important consideration is the neuroprotective effect of hypothermia. The medical literature and the lay press are replete with examples of survival after lengthy submersion in frigid or near freezing water. Cold-water submersion does not guarantee survival but may play a significant role in management decisions during and after the resuscitation. The term \u201csecondary drowning\u201d typically refers to patients who survive the submersion injury for some period of time, yet later develop respiratory failure and death attributed to the original submersion event. This deterioration may occur from hours to days later. While the term \u201cdrowning-related death\u201d has been proposed to describe deaths occurring more than 24 hours after a submersion, this definition is not widely used. \u201cNear drowning\u201d is defined as immediate survival after a submersion event. While most of these individuals may survive, many will deteriorate. The definition has some variability among authors and published sources, with some including asphyxia or loss of consciousness in the definition. There remain ongoing efforts to better formalize definitions, including the use of the term \u201cdrowning\u201d (defined as a process resulting in primary respiratory impairment from submersion and immersion in a liquid medium) to classify all events regardless of outcome as drowning. To date, this has not been widely accepted in medicine or by the lay public. The remainder of this chapter will distinguish drowning (death) from near drowning.",
        "Dispatch life support": "Emergency dispatchers should provide dispatch life support, including standard respiratory and/or cardiopulmonary arrest instructions. Minimizing delays in delivering instructions is essential. DeNicola showed that 42% of children drowning in home swimming pools were rescued by bystanders but did not have CPR initiated until EMS personnel arrived. The use of an automated external defibrillator (AED) is appropriate and should be included when such a device is available. A less clear area is whether dispatchers should direct callers to rescue drowning victims. All water rescues involve risk and may potentially result in additional victims.",
        "Scene and crowd control": "The first step in successful drowning management is rapid extraction of the victim from the water. Scene safety is paramount, especially in natural water and moving water scenarios. Rescuers not specifically trained in water rescue should not attempt extraction or rescue in moving water.\n\nCrowd control and prevention of secondary victims are essential. Drownings are dramatic events. Depending on the setting (public pool, hotel pool, natural water setting), a large number of bystanders may be present. Bystanders acting as rescuers may inadvertently become secondary victims, especially in natural water settings or in large groups with several non-swimmers. Rescuers should liberally request and utilize crowd control resources.",
        "Management of the drowning victim in cardiac arrest": "The most dramatic clinical presentation of drowning is cardiopulmonary arrest. Rescuers should initiate standard BLS, ACLS, and Pediatric Advanced Life Support (PALS) protocols on drowning victims in cardiac arrest. CPR should begin as soon as practical, with some advocating initiation of CPR while the victim is still in the water. Airway management should begin immediately with bag-valve-mask (BVM) ventilation. Typically extrication from the water should not be delayed for more definitive airway management. Once extricated from the water, additional airway procedures consistent with cardiac arrest protocols may be considered. Rescuers should anticipate vomiting, which may occur in up to 86% of drowning victims receiving rescue breathing and chest compressions. Maneuvers to clear water from the lungs, such as laying the patient prone and lifting the arms behind the back toward the head, are not necessary and should not be performed. Cardiac arrest treatment algorithms do not require modification for drowning victims. While experts have historically emphasized minimizing movement in the severely hypothermic patient to avoid precipitating ventricular dysrhythmias, this recommendation seems to be based more on theory and conjecture than data. Advanced airway management is appropriate in services and personnel competent in the skill. Airway management while in the water is fraught with difficulty and risk of aspiration and delay of CPR initiation. While each scene may pose a unique risk-benefit analysis around patient access and timely egress, typically anything more than basic maneuvers should be deferred to accomplish rapid extrication and initiation of full resuscitation efforts. In the severely hypothermic patient, advanced airway placement may allow for warmed, humidified ventilation. Vascular access and drug therapy should follow standard resuscitation protocols. Some experts have raised concerns that medications may reach toxic levels in the circulation due to decreased metabolism in the severely hypothermic patient. However, little scientific evidence distinguishes drug metabolism in hypothermic versus normothermic cardiac arrest patients. Despite this concern, most guidelines recommend minor alterations of cardiac arrest protocols for patients with hypothermia. Specifically, in moderate hypothermia (30\u201334\u00b0C), rescuers may increase the time interval between intravenous medications. Rescuers should also perform active external rewarming for moderate-to-severe hypothermia. For severe hypothermia (<30\u00b0C), current ACLS guidelines recommend providing a single defibrillation attempt and withholding intravenous medications until the core temperature is >30\u00b0C. The determination of an accurate core temperature in the field setting is difficult, and rescuers should base their actions on the best available clinical information.",
        "Management of near drownings": "By definition, the near drowning patient has vital signs. Near drownings may include patients who never lost vital signs, and those successfully resuscitated. Airway management, hemodynamic stabilization, and transport are the mainstays of treatment. These individuals may be apneic, hypotensive, or hypothermic and should receive appropriate resuscitative interventions. Near drowning victims have strong potential for pulmonary injury and should receive emergency department evaluation. Over half of near drowning victims ultimately require hospital admission. Near drowning victims should be transported and evaluated, as initial presentation can progress rapidly, and refusals should be strongly discouraged.\n\nField management should focus on management and evaluation of oxygenation. Monitoring of pulse oximetry, cardiac rhythms, vital signs, and overall neurological status is warranted. Monitoring of end-tidal CO\u2082 may also be helpful. Continuous positive airway pressure (CPAP) in the conscious breathing patient is being increasingly advocated. Rapid deterioration in ventilation, oxygenation, or ability to protect the airway may require more aggressive airway management techniques consistent with medical respiratory distress protocols. Secondary aspiration from vomiting is a risk in the declining near drowning victim. Intravenous access should be established in most near drownings. Consideration should be given to potential concurrent trauma. Victims may have had concurrent medical conditions that triggered the event, such as hypoglycemia, seizures and cardiac dysrhythmias. These should be addressed and treated appropriately.",
        "Management of concurrent trauma": "Many drownings occur concurrently with other major trauma. For example, an individual may sustain a cervical or spinal cord injury after diving into shallow water. Swimmers in lakes have sustained traumatic brain injuries or penetrating trauma after being struck by motor boats.\n\nThe most important consideration in drowning victims is the potential for cervical spine injury. Hwang et al. identified seven cervical spinal injuries in 143 pediatric drowning and near drowning patients transported to a pediatric trauma center. Watson et al. identified 11 cervical spine injuries in 2,244 drowning victims. All patients in each series were identified with mechanisms of injury suggestive of trauma (diving, high-impact, or assault).\n\nEmergency medical services rescuers should consider cervical spine injuries in all diving, high-impact (e.g. dive from a height), white water, and submersion injuries. However, the rescuers must weigh the risks and benefits of cervical immobilization. For example, cervical immobilization may be dangerous and difficult in swift water rescues. Current American Heart Association guidelines state \u201c\u2026 routine stabilization of the cervical spine is not necessary unless the circumstances leading to the submersion episode indicate that trauma is likely \u2026\u201d Drowning circumstances potentially linked to cervical injury include a history of diving, water slide use, concern for alcohol intoxication, or physical signs of injury. The decision to initiate spine immobilization while in the water is a risk-benefit decision for the patient and rescue team. An absence of identified risk for cervical injury precludes the need for spine immobilization in or out of the water. Swimming pools in particular may be a more appropriate setting for floating backboards or baskets and application of cervical collars without undue risk to the patient or the rescue team. Swift water environments may require a more limited cervical spine control maneuver and rapid extrication to the water\u2019s edge prior to application of rigid collars and boards. In all events, if secondary concerns for cervical injury are discovered by examination or history, cervical protection measures should be instituted.",
        "Rewarming of drowning victims": "Rewarming is appropriate for severely hypothermic patients. Initial thermal management begins with removal of the patient from the offending environment. The patient should be removed from the water. The resuscitation effort should continue in a warmed environment. EMS rescuers should prewarm the ambulance if possible. To prevent further heat loss, the patient\u2019s wet clothing should be removed.\n\nAdditional rewarming techniques are commonly classified as active external rewarming and active internal rewarming. Active external rewarming includes the use of warm packs, warm water packs, forced air, thermal blankets, warmed O\u2082, and warmed IV infusions. Care should be taken to avoid secondary thermal injury from warm packs against the native skin. Concern for a paradoxical drop in the core temperature due to vasodilation of the peripheral vasculature during rewarming has been postulated. Careful hemodynamic monitoring should be instituted.\n\nActive internal rewarming includes the use of peritoneal lavage with warmed fluids, esophageal tubes for rewarming, chest lavage with warm fluids via chest tubes, and the cardiac bypass or extracorporeal circulation; these measures are typically not carried out in the prehospital environment.\n\nTraditionally, most experts argued for rewarming by whatever means available and to do so aggressively during the resuscitation. The old adage \u201cA victim is not dead until warm and dead\u201d may require reconsideration. Mounting evidence has shown that induced hypothermia after return of spontaneous circulation may impart some neurological benefit for ventricular fibrillation arrest and possibly other arrhythmias. It would seem logical that a drowning victim may benefit from induced or continued hypothermia. Additionally, ACLS guidelines now target core temperature to 32\u201334\u00b0C with return of spontaneous circulation in cardiac arrest due to accidental hypothermia. In the absence of specific drowning data, and the success of prehospital hypothermia in general cardiac arrest, the historic practice of aggressive rewarming is being questioned. Some in medicine are specifically calling for abandoning the practice altogether.",
        "Destination decisions": "Patients in cardiac arrest should be transported to the nearest emergency facility. Patients with perfusing rhythms may benefit from transport to a specialized facility (for example, trauma or pediatric center), provided that the additional transport time is limited. While many victims have concurrent trauma, it is not clear whether transport to a trauma center is warranted for all drownings.",
        "Grief reactions": "Drownings are unexpected events in typically young and healthy patients. Relatives and bystanders may express significant grief from these events. After the incident, attention should be paid to possible grief reactions in rescue personnel so that appropriate referral or interventions can be implemented."
    },
    {
        "Introduction": "Physicians providing EMS medical oversight and those providing direct patient care in the prehospital environment must possess a significant level of expertise in the use of non-invasive and invasive procedures for the prehospital stabilization of trauma patients. The nature of the care and the procedures that are appropriate for different levels of providers is based on the education, training, and legal scope of practice of the providers in the EMS system. An EMS physician must be skilled in these procedures and maintain active educational programs and continuous quality improvement activities to insure these procedures are being performed correctly, and under the correct circumstances. In some cases, it may be appropriate that only an EMS physician perform a procedure, either due to special circumstances or due to the provider\u2019s ability and/or scope. Appropriate hands-on and didactic training, as well as verification of procedural proficiency, should occur prior to implementing any procedural skill.",
        "Needle thoracostomy": "The placement of a needle to relieve tension pneumothorax is often used in ground EMS systems. Some air medical (and critical care) services have also authorized the placement of a formal tube thoracostomy by their crews. The placement of a needle into the pleural space can produce dramatic results in a patient suffering from a tension pneumothorax.",
        "Needle thoracostomy - Indication": "This procedure should be considered in any patient who suffers from rapid cardiopulmonary decompensation in an appropriate clinical setting. Although tracheal deviation and decreased breath sounds are commonly accepted as signs of a tension pneumothorax, they may not always be present and may not be appreciated in some prehospital environments. Providers should be encouraged to perform this procedure in any blunt chest trauma patient who has a precipitously decreasing course, especially if there is a history of chronic obstructive pulmonary disease or asthma. Trauma patients with obvious subcutaneous emphysema can benefit from the early application of this technique. Eckstein and Suyehara reviewed their experience in a series of over 6,000 trauma patients. Their conclusion, based on the 108 patients in this series who received needle decompression, was that this was a potentially life-saving intervention, with a low complication rate. If the catheter is placed into the lung parenchyma, the puncture will be small and should heal rapidly. The resultant pneumothorax is an open one, and therefore the patient should suffer little further compromise. If the patient is intubated, the thoracostomy catheter may be placed and left open to the air. If the patient is spontaneously breathing, a one-way valve must be created to prevent reentry of air during inspiration. One-way valves, such as the Heimlich valve, are available with tubing that will connect with a standard venous catheter. Condoms may be used by puncturing the condom with the catheter and then unrolling it after the catheter has been placed in the patient. Surgical gloves have been used, but when compared with condoms, they may produce unacceptable air leakage. Some services will use an aquarium air pump check valve, but despite anecdotal success, there do not appear to be any available scientific data evaluating their use for this purpose. Other devices, such as the McSwain Dart, have also been used for chest decompression, but they confer no demonstrated advantage over a venous catheter. For most EMS systems, needle thoracostomy is the safest, most rapid, and most effective way of providing pleural decompression.",
        "Needle thoracostomy - Technique": "Locate the second intercostal space, in the midclavicular line on the anterior chest wall of the affected side. An alternative site is the midaxillary line at the level of the nipple, similar to the usual chest tube site. Apply best possible sterile skin preparation with sterile prep. Load the pneumothorax catheter onto the tip of the 10mL syringe. Direct the catheter perpendicular to the skin, keeping in mind that ideal placement is over the top of the rib and not into the inferior portion of the superior rib which risks damaging the neurovascular bundle. Enter the skin and, while gently withdrawing on the plunger, advance the catheter until air moves freely into the syringe (with or without blood return). The plastic catheter should then be advanced off the needle and into the chest. The syringe (frequently a larger syringe) may be used in conjunction with a stopcock to aspirate the air from the pneumothorax until resistance is noted on the plunger. A one-way valve may then be connected to the end of the catheter. A definitive thoracostomy tube will need to be placed after acute decompression with needle thoracostomy (typically in the hospital setting or in critical care transport situations).",
        "Needle thoracostomy - Complications": "The rate of significant complications is thought to be low. It is possible to puncture the subclavian vein and/or artery if the second interspace technique is done improperly and the needle is placed too high on the chest. If the lateral approach is used, abdominal organ injury may result from a needle placed too caudal. Laceration of the internal mammary artery and the risk of infection are two other complications to consider. Care is needed to avoid these complications by providing the best available level of preprocedural cleaning and utilization of landmarks when placing the needle.",
        "Tube thoracostomy": "This common surgical procedure, mostly limited in the field to air medical services or military situations, is used to evacuate air or blood from the pleural space. It is particularly useful when transport times are sufficiently long. Once the tube has been secured, one must decide what to do with the free end of the tube. If the patient is intubated the tube may be left open, creating an open pneumothorax. For a patient who is not intubated, a one-way valve must be created to prevent entry of air into the thorax during inspiration. The Heimlich valve, essentially a rubber flapper valve in a tube, is the most practical device for the paramedic. It may be connected to suction if required, and if there is a large amount of drainage, a urinary catheter bag may be attached to collect the drainage.",
        "Tube thoracostomy - Indication": "The ability to rapidly evacuate a large amount of blood from the trauma patient's pleural space, converting a tension hemothorax into an open hemothorax, is this technique\u2019s primary advantage. In some cases this may be life-saving but in others, the patient can exsanguinate from the tube, depending on the source of the bleeding. Placement of the formal thoracostomy tube may also be indicated if a large pneumothorax is present and a long transport time is expected. Potential advantages are the lower likelihood of kinking, clotting, and dislodgment of the tube in comparison to the needle technique.",
        "Tube thoracostomy - Technique": "Abduct and externally rotate the arm on the affected side so that it is up and out of the way. Locate the fifth intercostal space, in the midaxillary line on the chest wall of the affected side. Apply best possible sterile skin preparation with sterile prep. Locally inject the site with anesthetic. Using the #10 blade scalpel, make a 3-4 cm transverse incision onto the fifth rib at the midaxillary line. With a large Kelly clamp, bluntly dissect over the top of the fifth rib into the fourth intercostal space. Some force may be required to enter the pleural space and the operator should feel a definitive pop upon entering the pleural cavity. At this point, there may be a rush of air and/or blood. Spread the tips of the Kelly clamp in the pleural cavity to widen access, then turn the clamp 90\u00b0 and spread again. Insert a gloved finger into the pleural space to verify proper position and to hold the track while guiding the chest tube into place. The Kelly clamp may then be removed at the provider's discretion. The tube may be inserted directly or facilitated by the use of a Kelly clamp to grasp the tip, through the eye, to help guide the tube. The tube should be inserted along the tract and into the pleural cavity, while directing it posteriorly and superiorly. The tube should slide smoothly without significant resistance and all of the fenestrations must be inside the chest wall to allow for suction.\n\nIf the tube will not advance, the operator may attempt to turn the tube; however, if the tube is drawn out of the chest, a new tube should be used on the next attempt to place through the same tract.\n\nOnce the tube is in position, secure the chest tube to the chest wall with a silk suture. Petroleum gauze with a single cut halfway across the middle of the gauze can then be placed around the tube. Dry gauze, with the same cut, is then placed over the petroleum gauze and the elastic adhesive tape is used to hold the dry gauze in position. The tube is then bolstered and taped to the chest wall. The end of the tube should then be connected to the chest tube drainage apparatus, or a Heimlich (one-way flutter) valve should be placed on the end.",
        "Tube thoracostomy - Complications": "The tube should be placed under sterile conditions. However, this may be difficult or impossible based on the potential pre-hospital environments in which this may be performed. This may lead to empyema, should the patient survive. Placement in the wrong interspace can result in injury to the abdominal organs, the heart, or great vessels, and the use of trocars or Kelly clamps to place the tube may cause injury to the lung parenchyma or other thoracic structures.",
        "Pericardiocentesis": "Pericardiocentesis is classically taught as the procedure of choice for treating cardiac tamponade. Its use in the prehospital setting has not been fully investigated. In the patient suffering from pulseless electrical activity (PEA) due to cardiac tamponade, pericardiocentesis may theoretically restore a perfusing rhythm. Medical directors may wish to include pericardiocentesis in a traumatic PEA protocol; however, its use should typically be reserved for patients in whom fluid challenge and needle thoracostomy have not resulted in palpable pulses.",
        "Pericardiocentesis - Indication": "The indication for this intervention is the presence of life-threatening physiological changes with signs of traumatic cardiac tamponade. The Beck triad (muffled heart sounds, jugular venous distension (JVD), and hypotension) and Kussmaul signs (pulsus paradoxus, a drop of >10 mmHg during inspiration, and paradoxical increase in JVD, as a sign of increased jugulovenous pressure) are indications of cardiac tamponade. Cardiac tamponade is present in up to 90% of penetrating injuries to the heart.\n\nPericardiocentesis is also indicated for resuscitation of a patient with PEA when other causes have been ruled out and the patient remains pulseless. Pericardiocentesis has been reported successful even in cases of cardiac tamponade from blunt trauma.",
        "Pericardiocentesis - Technique without ECG or ultrasound guidance": "Expose the subxiphoid region and prep the area with sterile antiseptic solution. Position an 18 G (either 3.5 or 6 inch) spinal needle so that it will enter the skin directly below or adjacent to the xiphoid process. The needle should be held at a 45\u00b0 angle to the skin, aiming at the left shoulder (assuming normal anatomy). This technique minimizes the likelihood of injuring other important structures. The needle is advanced, maintaining angle and direction, while withdrawing on the plunger. The operator stops advancing when blood returns. After removal of up to 50 mL of blood, vital signs are reassessed. In cases of acute tamponade, removal of as little as 25\u201330 mL can lead to immediate improvement. If hemodynamic status does not improve, perform additional aspiration of blood in 25 mL increments until condition improves. The stopcock may be place on the Luer-Lok end of the spinal needle and may be used for subsequent drainage (either through tubing into a bag or into a syringe with aspiration). If the needle is left in place it must be stabilized. If removed, the operator should consider drainage of pericardial blood until little to no blood returns, and then check for reaccumulation prior to removal. A sterile dressing should be placed over the site. At this point, if equipped, the operator may choose to utilize the Seldinger guidewire technique and place a flexible plastic catheter instead of leaving the metal spinal needle.",
        "Pericardiocentesis - Technique with ECG guidance": "Prior to initiating the procedure described above, the operator uses an alligator clip jumper cable to bridge from the ECG lead (V1 in the case of 12-leads, lead II for 3-lead) to the proximal metal portion of the spinal needle. The same procedure may be used, and advancement of the needle is now additionally guided by blood returned and the change on the ECG lead to ST elevation on the monitor. The rest of the procedure is the same as above.",
        "Pericardiocentesis - Technique with ultrasound guidance": "If prehospital ultrasound is available, it may be employed to guide placement of the needle into the pericardium. The operator will identify the point of maximal effusion in order to guide site selection. The site should represent a superficial access to the effusion and will not likely be the subxiphoid site, due to the ability of the ultrasound to visualize both the effusion and the needle during the procedure. Angle and depth will be guided by the ultrasound. The operator should use the probe before (to identify the site) and during the procedure (in order to guide the needle to the effusion), and after initial drainage (to check for reaccumulation). The rest of the procedure is the same as the blind technique above.",
        "Pericardiocentesis - Complications": "Classically, the use of this technique has been discouraged in the patient with a traumatic tamponade as it may delay the implementation of thoracotomy. Thoracostomy is not usually available in the prehospital setting unless a properly trained and equipped EMS physician is present. Theoretically, the needle could also cause injury to the myocardium or puncture or lacerate a coronary vessel.",
        "Spinal immobilization": "The most critical aspects of patient packaging are those interventions designed to protect the spinal cord from further injury. Before the appearance of organized EMS services and paramedic training, motor vehicle crash victims were often extricated and transported without the use of any form of spinal immobilization. These patients were simply pulled from their vehicles or placed on stretchers without any consideration of splinting or spinal stabilization. It was reported that patients presented to the hospital with completed spinal cord injuries. Immobilization has since become one of the most fundamental interventions provided by prehospital providers. Although this process has been accepted for decades, no formal studies have assessed its validity or effectiveness, and it is not without its problems. Changes in automotive design since the institution of spinal immobilization in the 1960s have led some to question the need for universal spinal immobilization of motor vehicle crash victims. Like so many prehospital interventions, this is a difficult procedure to study given the current medicolegal climate. In light of recent studies exposing the lack of evidence of the effectiveness of cervical collars and long spine boards in the maintenance of spinal alignment, coupled with the detrimental effects of routine immobilization, it is important to carefully consider protocol design and quality assurance processes in order to limit the adverse effects of this now ubiquitous but not evidence-based practice.",
        "Spinal immobilization - Indications": "Spinal immobilization has been considered important for a wide variety of mechanisms including motor vehicle crashes, falls, and athletic injuries. Even falls from the standing position, especially in the elderly, may result in spinal injuries. Despite the routine use of spinal immobilization in trauma victims, indications for use in prehospital care remain an active area of research. Although occult spinal injuries may be difficult to detect reliably in the field, studies have noted the discomfort caused by the use of backboards and collars and have questioned whether immobilization should be performed in the absence of signs and symptoms. Recent studies have reported a lack of effectiveness in spinal immobilization using a long spine board. Multiple authors have questioned the utility of backboard use due to a lack of data to support their effectiveness in preventing secondary injury, and the documented potential harm associated with backboard use including iatrogenic pain, skin ulceration, increased use of radiographs, aspiration, and respiratory compromise. The National Association of EMS Physicians (NAEMSP) and the American College of Surgeons Committee on Trauma (ACS-COT) joint position paper on the topic notes the risks associated with the use of long spine boards and cites the need to remove the patient from them as soon as possible. A 2013 paper suggests the mean backboard time for patients might be nearly an hour. Based on available evidence, limiting the use of long spine boards to extrication, and removing the patient from the board while maintaining spinal precautions, may be preferable.",
        "Penetrating trauma": "In some geographical areas, gunshot wounds are the leading cause of spinal cord injuries, whereas nationwide they are the third most common source of spinal injury. Although well accepted for blunt trauma, the tactical EMS community, citing data from the WDMET study of Vietnam War casualties, has actively discouraged the use of spinal immobilization for gunshot wounds. These studies suggest that the injuries to the spinal cord from bullets are either complete at the time of wounding or are stable and do not require immobilization. Heck et al. also point out that cervical collars may preclude good observation in patients with neck wounds. A review of the Israeli experience with penetrating neck trauma concurs with this view. Jallo agrees that spinal instability is rare with these types of penetrating injuries, but cautions that \u201coptimal management has not been determined\u201d. Other authors have advocated for a middle ground, suggesting that if the cervical collar interferes with patient care then it can safely be removed, but that otherwise it should be left in place. However, the 2013 NAEMSP and ACS-COT joint position statement on use of long spine boards states that patients with penetrating injury and no signs of spinal injury should not be immobilized on long spine boards.",
        "Blunt trauma": "Immobilization for blunt trauma and falls has been studied in much better detail. Domeier et al. retrospectively reviewed a large group of patients with spinal fractures in Michigan. They concluded that patients with altered mental status, neurological deficit, spinal pain, evidence of intoxication, or suspected extremity fracture were more likely to have significant spinal injuries. In a further study, Domeier et al. prospectively reviewed the above set of spinal immobilization criteria and found that these criteria would have been 95% sensitive and 35% specific, and had a negative predictive value of 99.5% for spinal injury. Domeier suggested that if applied clinically, these criteria might have reduced spinal immobilization by as much as 35%. He pursued this concept by applying the criteria in a prospective clinical study, finding a 39% reduction in spinal immobilization. In this study, the criteria were found to be 92% sensitive and 40% specific. Of the 8% (n=33) of patients with spinal column injuries that were missed, none had documented spinal cord injuries. Of these 33 patients, 18 had immobilization techniques applied at the hospital. Seventeen of the 33 missed patients were over the age of 70. During retrospective chart review, the authors reported some difficulties with algorithm non-compliance and incorrect assessments by prehospital personnel. In a similar study, Muhr\u2019s group attempted to reduce spinal immobilization use in trauma patients who did not meet trauma system activation criteria. They prospectively applied an eight-point immobilization algorithm. Before algorithm application in their system, 98% of these patients were spinally immobilized. The authors demonstrated a 33% decrease in immobilization. Interestingly, spinal immobilization for blunt trauma is not practiced throughout the world. In a unique comparative study, Hauswald et al. compared neurological outcomes between immobilized and unimmobilized blunt trauma victims in New Mexico and Malaysia. In the Malaysian system, none of the patients received any form of prehospital spinal immobilization, while in the New Mexican system, all studied patients were immobilized. Their results indicated that there was less neurological injury in the Malaysian population than in the New Mexican group. This study has significant limitations, which are described in an accompanying editorial by Orledge and Pepe, but the findings are intriguing nonetheless. Hankins et al. describe another set of clinical criteria that may be used to indicate which patients might be eligible for clinical spinal clearance: no extremes of age (<12 or >65 years old), no altered mental status or language barriers, no neurological deficits, no distracting injuries, and no midline or paraspinal pain or tenderness. Again, it is important to note that NAEMSP/ACS-COT position statement also includes the concept that maintenance of spinal precautions does not require use of a long spine board.",
        "Application of cervical collar": "The first step in spinal immobilization is typically manual stabilization of the head, followed by placement of a rigid cervical collar. Numerous collars are available on the market, ranging from cloth-covered foam rubber to stiff plastics of various designs. The soft collar provides no immobilization and has no place in prehospital care.",
        "Application of cervical collar - Indication": "Immobilization of the cervical spine is performed to avoid secondary injury in patients who have the potential for unstable fractures. In a 1986 study, McCabe and Nolan compared cervical spine motion on radiographs with volunteers immobilized in Philadelphia, hard extrication, and two versions of the Stifneck collar. The Stifneck collars were better than either the Philadelphia or hard extrication collars in immobilizing the patient in all directions except extension. Dick and Land, in a review of all spinal immobilization devices, found that the Stifneck collar provided the best immobilization among all collars tested. A number of similar plastic collars are currently available, but limited data are available regarding the effectiveness of specific devices. Regardless of the brand utilized, the collar should be made of rigid plastic and sized properly for the patient's neck. Due to the controversy surrounding the utility of the cervical collar and complications it may cause, some authors have advocated very limited use or for spinal precautions only.",
        "Application of cervical collar - Technique": "To ensure the best potential patient outcome, the cervical collar must be properly sized prior to placement. The operator holds out his or her hand and extends all of the fingers. The hand is placed on the side of the neck with the pinky almost touching the shoulder. An imaginary line from the inferior chin is considered and matched up to one of the fingers on the measuring hand. The hand can then be matched up to the cervical collar and the collar adjusted to the correct height based on the distance between the sizing mark/line on the collar and the bottom of the plastic portion of the collar. The chin section of the collar is placed into position first, with the rest of the collar then wrapped around the neck. Allowing for a snug (not tight) fit, close the collar with the hook-and-loop fasteners. The collar should be snug enough to keep your patient from flexing and extending the head, but not so tight as to stop the patient from being able to open the mouth. Immobilization with the cervical collar may be enhanced when used in conjunction with head blocks and the long spine board.",
        "Application of cervical collar - Complications": "Application of an improperly sized collar is very uncomfortable for the patient and may be counterproductive to the goal of spinal immobilization. In patients for whom no collar seems to fit properly, padding with towels and securing the head and Torso directly to a spine board or extrication device may be preferable, though data are limited. Respiratory compromise and vascular occlusion can occur when not properly fitted.",
        "Application of a long spine board (backboard)": "Since the late 1960s the long spine board has been considered an important component of prehospital trauma care in the United States. If immobilization is thought to be clinically useful for a given patient, then proper application and technique should be observed.",
        "Application of a long spine board (backboard) - Indication": "NAEMSP/ACS-COT position paper on use of spinal precautions and long spine boards states that spinal precautions may be appropriate in patients with blunt trauma and altered level of consciousness, spinal pain or tenderness, a neurological complaint (numbness or motor weakness), anatomical deformity of the spine, or a high-energy mechanism of injury and any of the following: drug or alcohol intoxication, inability to communicate, or distracting injury.",
        "Equipment": "Several immobilization devices are available, each with a slightly different application technique. Devices commonly in use include long spine board, scoop stretcher, vacuum mattress, and the Kendrick Extrication Device (KED).",
        "Long spine board technique": "Throughout the procedure, manual inline cervical spine alignment must be maintained until the cervical collar is placed correctly. One team member will maintain manual inline cervical stabilization during all movements. Team members should respond to the leader\u2019s commands and count to ensure synchronicity of movement in order to maximize spinal immobility. The team may use the logroll technique or the lift and slide technique to place the patient onto the long spine board. The patient is then strapped to the board. The chest strap is usually secured first, followed by the waist and then the thighs and lower legs. All voids between the board and the patient should be padded. The head is always immobilized last. Head blocks are placed on either side of the head. In some cases, occipital padding may be needed. The head may then be secured using tape or commercially available straps.",
        "Scoop stretcher technique": "As with the long spine board technique, the cervical spine should be immobilized and the provider at the head should command the operation. The scoop stretcher is opened and placed with the hinged portion at the head with the open portion toward the feet (or it may be taken completely into two halves). The scoop stretcher is then closed under the patient. If the patient is not on a smooth hard surface, pinching may occur at the buttocks and/or the shoulders. In order to decrease pinching, gentle lateral traction on the patient's clothing may help. If the patient is on a sheet, the sheet should be pulled tight during the procedure to limit the potential for pinching. The head (first) and foot (second) hinges are locked. The patient is then strapped to the stretcher (chest, waist, legs, then head).",
        "Vacuum mattress technique": "First the vacuum mattress is inspected and laid flat on the ground. If there are any holes or tears, this technique must not be used. The vacuum valve should be facing up and be positioned at the patient's feet. The patient is then placed on the mattress (lift and slide, logroll off a backboard, placed onto the mattress using a scoop stretcher, or logroll onto a sheet on top of the mattress) and positioned onto the middle of the mattress. The mattress is pumped several times to make it slightly firmer. The mattress is then molded to the patient and the straps are placed. The mattress is molded around the head manually and the mattress pump is used to vacuum the air from the mattress until it is firm and in a molded form. The mattress can be moved on a long spine board or in some cases may be carried with straps if it is sufficiently rigid in the vacuume state and has been designed for this use.",
        "Extrication device technique": "Once a stiff cervical collar is placed, a team member must place the extrication device behind the patient in the upright position, aligning it with the patient. The middle torso strap is secured first, followed by the bottom torso strap. The leg straps and top torso strap are then secured, followed by the head strap, with adequate padding to fill voids. The patient is then extricated using the extrication device haul straps and placed on the long spine board. At this point the operator will disconnect the leg straps, allowing the patient's legs to lie flat on the long spine board. The patient is then secured to the long spine board while still in the extrication device.",
        "Application of a long spine board (backboard) - Complications": "Complications associated with spine board use include discomfort, increased use of x-ray in immobilized patients, potential for decubitus ulcer formation, and risk for respiratory compromise. Medical directors of EMS systems should actively investigate ways to ensure that only those patients who need this intervention receive it, and that those who are immobilized to long spine boards are removed from the boards into less harmful spinal precautions as early as possible.\n\nPregnant patients who are >20 weeks gestation may experience compression of the abdominal great vessels and should be positioned with the board wedged toward a left lateral slant while maintaining immobilization. Patients with respiratory distress or cardiac decompensation may need to be positioned in the semi-upright to upright position. In this case, use of a short board or extrication device alone may be necessary. If this Is also impractical due to body habitus, the cervical collar may need to be used alone while attempting patient positioning that maintains as much spinal immobilization as possible while avoiding life-threatening cardiopulmonary complications.",
        "Padding": "Due to the significant discomfort associated with spinal immobilization, alternative methods of immobilization have been proposed. Additional concern for elderly or bedridden patients is also appropriate considering the associated unequal areas of tissue interface pressures that may lead to tissue damage and breakdown. Hauswald et al. compared four spinal immobilization techniques with healthy volunteers: traditional backboard, blanketed backboard, backboard with gurney mattress, and backboard with gurney mattress and foam pad. Not surprisingly, they found these techniques were rated in the same order, from least to most comfortable. A study by Lerner et al. revealed that occipital padding to produce neutral positioning in spinal immobilization subjects does not reduce pain. Walton et al. described a significant reduction in discomfort, without reduction in the effect of immobilization, when the long board is padded with closed-cell foam. Another alternative to the standard long board is the vacuum mattress device. Multiple studies have shown marked advantages in comfort and some advantages in immobilization when these devices are employed. Another option is a specially designed air mattress. Several brands of approved spine board air mattresses are available. In a study by Cordell et al., a standard long board was compared to standard long board with air mattress. The two groups reported their discomfort on a 100mm visual analog scale. At 80 minutes the air mattress group reported a mean 9.7 mm rating, versus a 37.5 mm rating in the standard long board group. They also measured tissue interface pressures and found that the air mattress group had significantly less pressure at the occiput, sacrum, and heel. The time of spinal immobilization should be limited and consideration paid to measures to decrease the ill effects, especially in high-risk patients.",
        "Children": "Several commercial devices are available for immobilization of children. For smaller children, a short board, well padded under the torso, can be used. Markenson et al. described using the KED for pediatric immobilization. Because of its versatility with both adult and pediatric patients, they suggest that this is \u201can ideal device\u201d for pediatric immobilization. Although immobilization is meant to protect the spine from further injury, it may compromise ventilation. Even in the majority of children, who would be unlikely to suffer from chronic lung disease, spinal immobilization can produce a significant decrease in forced vital capacity. Providers must be ready to assist with ventilation, should immobilization result in respiratory compromise. Infants and neonates who are found adequately restrained in undamaged car seats, who do not require other assessment and/or interventions, may be best transported immobilized in the car seats.",
        "Selective spine immobilization": "Selective spinal immobilization was originally studied in the emergency department and its use has been extrapolated to the prehospital environment.",
        "Selective spine immobilization - Indication": "It is reasonable to employ protocols that limit spinal immobilization to patients in whom there may be some benefit. A number of studies suggest the validity of this concept and potential for successful implementation.",
        "Selective spine immobilization - Technique": "The selective spinal immobilization algorithms most commonly used in the emergency department for determining appropriateness of clinical clearance of the cervical spine are the NEXUS and Canadian C-Spine rules. Nexus asks the EMS provider to determine the absence of focal neurological deficit, midline spinal tenderness, altered level of consciousness, intoxication, and distracting injury before electing to omit application of spinal immobilization. The Canadian C-Spine Rule asks three questions:\n1.Is there any high-risk factor present that mandates radiography (i.e. age \u226565 years, dangerous mechanism, or paresthesias in extremities)?\n2.Is there any low-risk factor present that allows safe assessment of range of motion (i.e. simple rear-end motor vehicle collision, sitting position in ED, ambulatory at any time since injury, delayed onset of neck pain, or absence of midline cervical spine tenderness)?\n3.Is the patient able to actively rotate the neck 45\u00b0 to the left and right?\nBoth of these rules were developed to more appropriately guide the use of radiography in the emergency department and not to guide paramedics using selective spinal immobilization in the field. However, both rules have been studied in the prehospital environment and found to function effectively.",
        "Conclusion": "Emergency medical services physicians must provide effective and knowledgeable medical oversight for the application of trauma-stabilizing procedures in the prehospital environment. An EMS physician must be skilled in these procedures and maintain active educational programs and continuous quality improvement activities to insure these procedures are being performed correctly, and under the correct circumstances. Appropriate hands-on and didactic training, as well as verification of procedural proficiency, should occur prior to implementing any procedural skill."
    },
    {
        "Introduction": "Trauma is a disease whose severity is largely dictated by time and energy kinematics: time to definitive care, including operative intervention when required in a minority of cases, and energy mechanically transferred to the body to produce injury. Appropriate integration of out-of-hospital and in-hospital management of trauma can have a major effect on overall patient morbidity and mortality. Studies continue to clarify which out-of-hospital interventions truly benefit the patient and which interventions may actually worsen outcomes or delay more effective care options. Specifics on how mechanisms of injury, injury severity, available resources (including air medical services), provider training level, and specialty centers affect management and outcome of trauma patients have become clearer in recent years. Controversy exists as how to best balance the need for expeditious patient transfer from the out-of-hospital environment to in-hospital definitive assessment-based care with the patient\u2019s need for critical or time-sensitive interventions prior to hospital arrival. An ever-enlarging body of experience and scientific study is further defining what management options improve outcomes in specific subpopulations of trauma patients.\n\nIn short, trauma is a multifaceted disease that requires a systems-thinking and systems-operating approach, while incorporating new scientific knowledge to provide optimal patient management in the practice of EMS medicine.",
        "Effect on emergency medical services": "Proper assessment and management of blunt traumatic injuries are among the core goals for EMS physicians, paramedics, and EMTs. The physical demands encountered while managing the trauma patient can be considerable for EMS providers. Extrication from adverse environments and working in inclement weather are common. The ability to adapt the core trauma evaluation and management concepts to any given situation is paramount.\n\nEmergency medical services system structure elements, including ALS versus BLS, staffing level, and use of air evacuation resources, all contribute to a system\u2019s ability to care for the trauma patient. Scientific comparison of different operational models is just beginning to demonstrate which can provide the greatest benefit to specific patient populations. Long-held notions of the superiority of ALS interventions in the field (such as IV access for fluid resuscitation and endotracheal airway management) have been called into question. It may be that severely injured patients (at least in an urban setting) are best served by primary application of the basic skills of hemorrhage control, airway support, and rapid transport to the appropriate level trauma center.",
        "Training for EMS providers": "The central concepts for EMS providers caring for trauma patients include the following.\n\n1 Thorough training on a consistent, organized patient assessment algorithm that can be applied to any trauma patient, regardless of injury severity, is foundational. It should provide hierarchical management that focuses on identification and management of life threats, yet incorporates full, sequenced evaluation and integrated management options for actual and potential injuries. Frequent reassessments and ability to integrate information and recognize trends that require urgent intervention are essential.\n\n2 Efficient, appropriate use of local resources (air transport, hazardous materials, specialized rescue) and knowledge of hospital capabilities and destination policies (e.g. trauma center, pediatric trauma center, specialty burn care center) can improve patient outcomes in patients with significant, time-critical injuries. EMS systems should have policies and procedures to identify such patients and promote primary transport to the most appropriate facility. This concept, pioneered by trauma systems, is now being extended effectively to non-trauma disease processes such as acute myocardial infarction and acute stroke. Extrication-related issues that may affect management and timeliness of transport are addressed in Volume 1, Chapter 28.\n\n3 Proper use of spinal motion restriction, splinting, fluid resuscitation, and pain management to limit additional morbidity. Knowing how and when to properly use infrequent invasive procedures such as cricothyrotomy or needle thoracostomy is essential for patient safety and care.\n\n4 Universal precautions against blood and body fluid exposure and scene safety training are a vital component of every patient interaction, especially in traumatic injury, where the source of the injury (e.g. a downed power line, broken heavy machinery, or a collapsed building) may pose a serious ongoing threat to rescuers.\n\nMonitoring and reinforcing proper application of these concepts through performance measurement and improvement, together with adequate practice on infrequently used psychomotor skills, are important parts of medical oversight and can have a demonstrated effect on patient morbidity and mortality. Realistic, relevant, integrated assessment and management scenario-based training, potentially including high-fidelity like simulation, has been demonstrated to improve skill consistency and retention and may improve providers' ability to translate didactics into clinical performance. Nationally and internationally recognized courses that incorporate these elements exist and span the spectrum of care.",
        "Resuscitation and initial assessment": "The mechanism of injury, while not entirely predictive of actual injury sustained, often alerts the astute clinician to potential injuries that may be encountered during the assessment and management of the blunt trauma patient in the field. The importance of integration of local EMS and hospital resources, and tailoring guidelines to optimize patient care within these parameters, cannot be overemphasized. Blunt trauma management differs significantly from penetrating trauma.\n\nEmergency medical services systems should strive to limit the time from patient contact to departure from the scene to 10 minutes or less in injuries compatible with life threat. Except for control of life-threatening hemorrhage and support of airway and oxygenation/ventilation, all other interventions should take place en route to definitive care.",
        "The primary survey": "The goal of the primary survey is to identify and address any immediate life threats while the critical patient is promptly packaged for transport. Assessment can begin before arrival on the scene using dispatch information to prepare anticipated care needs based on patient mechanism of injury, potential notification of additional needed resources, and other local considerations.\n\nOnce patient contact is safely made, attention to discovering life threats through an organized approach is essential. Attention to arterial hemorrhage control, establishing and/or maintaining airway patency, correcting oxygenation and/or ventilation failure, and improving shock from blunt trauma are key aspects of the primary survey. In the severely injured patient with possible survival, the only survey to be done on-scene is the primary survey.\n\nScene photography may help convey aspects of mechanism of injury to the receiving physician as long as patient confidentiality is respected. Event data recorders (automotive \u201cblack boxes\u201d) will increasingly integrate with EMS to provide objective prearrival information in motor vehicle collisions (MVCs), potentially tailoring data-driven resource allocation based on actual mechanism and patient information. Newer telemedicine applications that allow concurrent assessment by EMS and receiving emergency physicians may facilitate triage and expedite care at the receiving facility for a number of time-sensitive medical complaints, including trauma.",
        "The secondary survey": "The secondary survey, like the primary survey, is conducted using an organized, consistent approach. It differs substantially from the primary survey in its detail. The secondary survey is a methodical head-to-toe assessment exam designed to identify many non-life threatening injuries that are easily obscured by visually captivating injury or primary survey life threat discovery. While important for all trauma patients, due to management priorities that are identified in the primary survey and require frequent reassessment, the secondary survey may not be performed until after arrival at the destination trauma center for some patients. Omission of the secondary survey for this reason is not incorrect and in fact, may represent a conscious decision by an astute EMS clinician to focus on immediate life threats identified in the primary survey.",
        "The role of Basic Life Support and Advanced Life Support": "Heated scientific debate continues over the value of out-of-hospital ALS in general, and in trauma care interventions specifically. Selection bias as well as significant variability in system elements and capabilities precludes a definite answer from existing literature at this time. Some evidence-based EMS practice recommendations have been extrapolated from the in-hospital literature, and their ability to translate into patient benefit in the out-of-hospital environment has yet to be demonstrated. A large-scale before-and-after study of ALS has cast significant doubt on the use of ALS in trauma. Initiatives that will provide national data collection and evaluation will foster more evidence-based implementation of patient management in the future. As a result, absent evidence to the contrary, EMS has used what are felt to be time-sensitive interventions that have demonstrated efficacy in the ED and other critical care environments.",
        "Constellations of blunt traumatic injury": "There are a number of recognized patterns of blunt trauma injury. For example, displaced sternal fractures are associated with a high risk of associated head, spinal, rib, and cardiac injury. The likelihood of intraabdominal injury to motor vehicle occupants increases significantly at speeds greater than 12 mph and exceeds 5% at 20 mph. Extensive abdominal injury evaluation due to mechanism of injury alone appears unwarranted in the absence of associated head, spine, chest, or leg injury. Scapular fractures are commonly associated with rib and lower and upper extremity injury resulting from the high kinetic energy transfer, but not with blunt traumatic aortic injury. Facial fractures due to assault and motor vehicle crashes are associated with intracerebral and pulmonary injuries with a high percentage of these patients requiring intubation during their inpatient course. Obesity (body mass index >30 kg/m) confers a risk for longer hospital and intensive care length of stay, as well as higher mortality in critical blunt trauma patients. Interestingly, head injuries are decreased in this population. Specific recommendations on management of traumatic brain injury and spine injuries are addressed in Volume 1, Chapters 30 and 36, respectively.",
        "Blunt trauma in pregnancy": "Blunt trauma in pregnancy\n\nTrauma is a leading cause for maternal mortality. Pregnant trauma patients should be managed with the maxim \u201cwhat\u2019s best for mom is best for baby.\u201d Supporting maternal oxygenation and perfusion is most likely to produce a positive outcome for both patients whenever possible.\n\nThe most frequent traumatic incidents affecting pregnant patients are MVCs. The majority of fetal deaths are due to MVC, with abruptio placentae and abdominal penetrating trauma as other common causes. A study of hospitalized pregnant trauma patients, 80% of whom were involved in MVCs, showed that predictors for fetal loss included higher injury severity score (ISS), maternal death, lower Glasgow Coma Scale score, abdominal abbreviated injury scale (AIS) score greater than 3, vaginal bleeding, and shock with significant base excess. Morbidity, mortality, and hospital length of stay were not significantly different in pregnant versus non-pregnant matched case controls.\n\nOne small study showed the overall immediate complication rate to be low, most commonly preterm labor and placental abruption. However, an increase in long-term complications was noted as well, with more severe trauma, multiple gestation, vaginal bleeding, and uterine contractions all being independent risk factors.\n\nDestination choice may be affected by potential fetal viability and immediate need for neonatal specialty care. Estimating potential viability at greater than 24\u201326 weeks gestation by history or palpation of the uterine fundus above the umbilicus can facilitate this decision-making process. Patients at greater than 20 weeks estimated gestational age should be placed with their left side elevated 15\u00b0, or up to 30\u00b0 of reverse Trendelenburg positioning, to relieve pressure on the great vessels, preventing supine hypotension and subsequent significant loss of preload and cardiac output. Although normal pregnancy-related changes in vital signs can imitate early shock, proactive oxygenation, fluid resuscitation, and monitoring are indicated to minimize risk of uterine hypoperfusion and fetal distress.\n\nEmergency caesarean sections are extremely rare and should be reserved for salvageable infants in selected situations, performed by adequate, trained staff including emergency physicians and obstetricians.",
        "Geriatric trauma": "With an ever-growing geriatric population, awareness of special considerations is important, particularly in trauma. Geriatric patients are more likely to have intraabdominal injury with concurrent head, leg, or chest injuries, regardless of MVC speed. CDC field triage criteria use age 55 as the break where patient management considerations change to recognize the increased risk of death from trauma after that age.",
        "Medical oversight issues in trauma": "Among the most important aspects of medical oversight is teaching the ability to effect a prompt and smooth patient transition from scene to hospital. Guidelines for management should be evidence based whenever possible and should take into consideration neighboring regions, hospital practice, and other regional specialty resources. Physician participation in regional and state medical oversight committees helps add clinical practice consistency while taking into consideration specific agency and provider capabilities, which may vary significantly within a locality. Monitoring of current literature and research allows the medical director to modify guidelines in keeping with national trends as tempered by local capabilities. Networking with inpatient physicians (particularly those in critical care, trauma, burns, and pediatrics) helps assure that EMS is focused on similar issues, using complementary technology and practice that will facilitate and expedite optimal patient outcomes both in the hospital and out of the hospital. Such networking will help limit \u201cus versus them\u201d attitudes toward EMS and reinforce that EMS is an equal and essential professional partner in the emergency health care team, dedicated to the same basic principles as the inpatient team.\n\nIn the case of trauma care, having specific, agreed-upon regional hospital triage criteria and guidelines on issues such as airway management, fluid resuscitation, medication management, spinal immobilization, and trauma alert categories all facilitate uniformity of in-hospital and out-of-hospital care. Ongoing monitoring of performance on established criteria, such as scene time in high-priority trauma, allows for modification of practice and assessment of effect of practice on patient outcomes.",
        "Guidelines for out-of-hospital management": "Guidelines for management of the trauma patient should be focused on providing necessary interventions, together with rapid transport to the closest appropriate facility. Triage guidelines should also address trauma patients who need different types of specialty care by identifying regional facilities with special capabilities such as pediatric trauma, burn care, hyperbaric therapy, and extremity replantation. Scene time should not be delayed while the provider waits for direct medical oversight.",
        "Air medical transport": "Transport of trauma patients by helicopter has become increasingly common in the United States in recent years. Its positive effect on saving the lives of combat casualties in the Korean and Vietnam conflicts, the Gulf War, and now Iraq and Afghanistan is well documented, though its effect on outcomes in specific civilian patient populations is still being studied, Staffing models vary significantly between the US and European systems. As such, use, patient injury severity, and effects on scene internal and mortality are difficult to compare.\n\nThere is recent concern that air medical transport may not uniformly provide added patient benefit for a number of reasons, including poor triage by field providers. Systems should implement guidelines to appropriately integrate valuable air medical assets into their trauma system, particularly given the cost and potential additional risks to both crew and patient.",
        "Hospital destination": "Patient outcomes are significantly better at trauma centers than at non-trauma centers. Both in-hospital and 1-year adjusted case fatality and relative death risk rates for moderately to severely injured patients are significantly better, typically with a 25% reduction in fatality risk. Studies support the importance of rapid transport to a regional trauma center where definitive care can be rendered. With the exception of safety issues, securing an unstable airway, and absent extrication issues, there is generally no indication for prolonging scene times, particularly in the severely traumatized patient.\n\nIt is crucial that the out-of-hospital provider rapidly and accurately identify the subset of trauma patients who may most benefit from trauma center management. The field triage decision scheme is fully described in Volume 1, Chapter 39. The most current version has shown efficacy and de-emphasizes trauma scoring, relying instead on progressive assessment of patient physiology, injury anatomy, mechanism, and special circumstances to provide trauma center destination guidance.\n\nProvider judgment has been introduced as a factor in decision making for transport to a regional trauma center in the field triage decision scheme. Trauma scores and mechanism of injury should not override provider judgment and divert a patient away from a trauma center.\n\nIntriguing new research raises questions on structure of hospital trauma systems. Inclusive systems, in which every facility in a region or state participates to the extent of their capabilities, are compared with exclusive systems, in which a limited number of high-level centers receive the majority of patients. In one study, the odds of triage to a regional trauma center and inpatient mortality were similar in both groups; however, the most inclusive systems were associated with the lowest odds of death.",
        "Trauma scoring": "Trauma scoring systems were first developed to attempt to quantify severity of injury and guide appropriate triage of patients to trauma centers. A variety of scoring systems exist, but their use is likely greater for research purposes than for patient care in the field.\n\nMultiple different scoring systems and permutations have been developed and continue to evolve to assist in predicting injury, need for emergency surgery, and outcomes. The Revised Trauma Score (RTS) is one of the more common trauma scoring systems. It combines the Glasgow Coma Scale score with respiratory rate and systolic blood pressure. Some systems, including the RTS and the ISS as well as derivations such as the survival risk ratio (SRR), have been used to predict patient outcome. Each trauma system must determine acceptable levels of overtriage and undertriage and how to best achieve these goals through ongoing quality improvement and surveillance.",
        "Prevention and other public health issues": "Trauma is largely a preventable disease with a tremendous cost to society. Although it affects all age groups, it is particularly devastating to the young and remains the major killer of North Americans under 40 years of age. As part of their role as advocates for their entire community's health status, EMS physicians and systems must play an active role in injury prevention.\n\nParticipation in community-based programs to encourage safer behaviors and risk reduction can reduce the number of injured persons. Programs such as helmet use, cycle and pool safety, proper use of car seats, and use of seat belts have all helped to reduce the number and severity of injuries. Programs targeting safe storage of firearms, reduction in drunk driving, and home safety assessments for elders can have positive effects on the community and may be led at the local, state, or national level. Local systems are able to tie into these resources without having to commit large amounts of financial and/or personnel support. This also represents an opportunity to put forward a proactive, positive \u201cpublic face\u201d for the EMS agency involved. The leadership for this effort must involve physician medical oversight. The CDC\u2019s Injury and Violence Prevention and Control page (www.cdc.gov/injury) is an excellent resource."
    },
    {
        "Introduction": "Traumatic eye injuries are extremely common in the prehospital setting, and may occur as isolated injuries or as part of more extensive maxillofacial or multisystem trauma. These injuries may range from the minor to the sight threatening, and EMS physicians must be prepared to rapidly identify serious problems that could result in permanent blindness or further complications. Once significant eye injuries are recognized, it is important that the patient is stabilized, appropriately treated, and evaluated by a hospital or physician with adequate access to full ophthalmological services to provide definitive care.",
        "Epidemiology": "Ocular trauma is common; in the United States an estimated 2\u20133 million people seek medical attention for eye injuries each year. Among many risk factors, the most significant seem to be male sex and age under 30. Most injuries are not significant, and many never need treatment for minor eye problems. Of those with more serious injuries, 16% have ocular or orbital damage and over 50% of patients with significant facial trauma have associated sight-threatening eye injuries. Trauma is the second most common cause of monocular blindness, trailing only cataracts. Each year, eye injuries are the number 1 cause of ophthalmological hospital admissions in the United States.",
        "Evaluation: history and physical exam": "Initial assessment and treatment should focus on the ABCs of trauma resuscitation, and any life-threatening injuries should be addressed first, as with any trauma patient. Eye injuries can be distracting, and it is important not to divert attention from other sources of serious injury early in the trauma survey process. It is also critical to recognize that associated facial trauma and swelling may affect airway patency, and this should be secured before further examination of the orbit if needed. After initial stabilization and primary survey, attention can be focused on the ocular injury and a thorough evaluation should be performed. In the case of known or suspected chemical contact to the face and eye, immediate irrigation with normal saline or clean water should be performed during this evaluation process. The key components in the evaluation of traumatic eye injuries are a thorough history and careful eye examination. The history focuses on key points surrounding the event and should note the type of injury, the time of onset, and any specific symptoms reported by the patient. Mechanism of injury is also recorded and may include blunt or penetrating trauma and thermal or chemical burns to the eye or periorbital areas of the face. Other important points include the patient's visual acuity before the injury, if known, the presence or absence of contact lenses, any past medical history of eye disorders, and any history of ophthalmological surgical or medical treatment. The physical examination of the eye begins with evaluation of visual acuity, establishing a baseline level of function and providing functional assessment of possible damage to the eye. In the field, this can be performed using a hand-held Snellen chart to document the smallest objects or letters identifiable at a specific distance from the eye. Visual acuity is recorded for each eye individually and then using both eyes simultaneously. If no chart is available, a newspaper or other source of small print is useful to estimate visual acuity. Patients who normally wear prescription glasses for reading should perform this with those same glasses if available, but those who use contact lenses should not have those replaced for this examination. If the patient's glasses are unavailable, it is possible to use a piece of paper with a small pin-sized hole through which the patient can view the chart and complete the examination. This \u201cpin-hole test\u201d corrects for the refractive error of the patient's eyes and should allow completion of the examination. For those who cannot read the Snellen chart due to injury or underlying ocular disease, other options include assessing the patient\u2019s ability to count fingers, detect hand motions, or perceive the presence or movement of light. The method of testing and patient performance should be documented for each eye. After rapid evaluation of visual acuity, attention shifts to the external assessment of the eye and surrounding structures. Each globe is examined for protrusion or proptosis and for external signs of penetration or damage from a foreign body. Ocular movement in the cardinal directions of gaze (vertical up-down, horizontal right-to-left, and diagonal left-to-right and right-to-left) is also tested and any deficit or entrapment recorded. The pupil and iris are then inspected for size, shape, and reaction to light and results compared between eyes. The presence or absence of a hyphema (blood in the anterior chamber that may obscure the iris or pupil) is especially important to assess. Finally, the conjunctivae are inspected for erythema, subconjunctival hemorrhage, chemosis, conjunctival swelling, or subconjunctival emphysema. If the patient reports a foreign body sensation in the eyelid or if there is any concern for an intraocular foreign body or a punctured globe, it is best to end the examination at this point. The affected eye should then be covered with an eye shield or improvised protective device to protect the globe from external pressure before transport for more definitive evaluation and care. The EMS physician should not remove a protruding foreign body (such as a nail) lodged in the globe. A cup or shield may be used to cover the eye with the foreign body in place. Finally, examination of the surrounding structures of the eye focuses on associated maxillofacial trauma or related complications. The eyelids and periorbital soft tissues are inspected for lacerations, ecchymosis, edema, foreign bodies, and cutaneous evidence of thermal or chemical burns. The orbital rims are similarly inspected and palpated for signs of crepitus or obvious bony deformities. If injuries are unilateral, comparisons are made between the eyes because normal foramina of the surrounding eye rim may be mistaken for fractures. If the patient has obvious periorbital trauma, an orbital blowout fracture is concerning, especially if there is associated diplopia (double vision) or inability to move the eye superiorly. Finally, the patient should have a sensory examination of the skin around the eye. Any numbness or paresthesias could indicate damage to the infraorbital nerve.",
        "Specific eye injuries - Ocular burns": "Ocular chemical burns are true ophthalmic emergencies and are best treated in the field with copious irrigation with water. Delays in irrigation have been associated with increased risks to visual acuity and higher rates of subsequent complications when compared with immediate irrigation of the eye. Tap water and normal saline work equally well initially, with the keys being the volume of the fluid and duration of irrigation rather than the type of fluid. Irrigation should continue during transport for a minimum of 30 minutes for significant exposures. Important historical information to obtain includes the duration of exposure, type of chemical, and the pH of the substance if known. If the chemical is an industrial source, a Material Safety Data Sheet (MSDS) is particularly helpful to identify and categorize the substance in question. Injuries from acid exposures tend to be less serious than alkali substances but this varies by the particular type of chemical involved. In addition to irrigation, proper prehospital management includes pain control and transport to an appropriate center for immediate ophthalmological consultation and evaluation.",
        "Specific eye injuries - Ocular trauma": "Direct trauma to the eye can be divided into open or closed globe injuries. Open globe injuries have full-thickness defects in the ocular wall and include lacerations, intraocular foreign bodies, and rupture of the globe from blunt trauma. These signify high-energy mechanisms of injury and are frequently associated with other ocular or periorbital injuries. Symptoms include decreased visual acuity, difficulty with ocular motility, and abnormal or absent pupillary reflexes. On examination, open globe injuries may be evident on gross inspection, as with a visible foreign body, a large scleral laceration with clear penetration, or an obvious deformity of the eye or pupil. However, penetrating injuries may cause negligible external damage to the sclera or globe and a small intraocular foreign body may cause minimal pain after the initial event. The key point for the prehospital physician is to consider an open globe, especially if there is associated significant head injury, periorbital damage, or hyphema. Once an open globe is suspected, all further evaluation of the eye should be postponed until definitive care is available. The eye should be protected with a hard eye shield and the patient should be transported for further emergency evaluation and potential surgical repair by an ophthalmologist. Other appropriate prehospital care includes pain control, elevation of the head of the bed to 30\u201345\u00b0, and antiemetic medication to reduce potential increased intraocular pressure during vomiting. Closed globe injuries occur when there is partial penetration of the eye and include hyphema, damage to the retina, superficial abrasions and lacerations, and non-penetrating foreign bodies. These can cause significant eye pain, loss of visual acuity, and decreased ocular function, but they vary by the type and location of injury.",
        "Specific eye injuries - Traumatic hyphema": "A traumatic hyphema is a collection of blood in the anterior chamber of the eye caused by blunt or penetrating injury. The highly vascular ciliary body or iris is usually the source of bleeding for a hyphema and is often associated with head trauma or other eye injuries to the cornea, iris, lens, or globe. Signs include decreased direct visualization of blood in the anterior chamber, poor visual acuity, and decreased pupil reactivity. Hyphema severity is graded on a scale of 1\u20134 based on the amount of blood that collects in the anterior chamber when the patient is in an upright position, ranging from a minimal layering (grade 1) to a complete filling of the anterior chamber with blood (grade 4). This classification is important because higher-grade hyphemas have an increased risk of complications and are a threat to permanent damage or loss of visual acuity. Complications include rebleeding into the hyphema, corneal blood staining, and damage of the optic nerve or retina from increased intraocular pressure. Prehospital care focuses on pain management, elevation of the head of the bed from 30\u201345\u00b0 if possible, covering of the eye with a protective shield, and prompt transport to a medical facility for further ophthalmological evaluation and management.",
        "Specific eye injuries - Corneal injuries": "Corneal injuries are extremely common and may present with ocular pain, sensations of a foreign body in the eye, blepharospasm, or tearing. Decreased visual acuity, blurred vision, and photophobia are also common initial symptoms. Corneal abrasions often result from a direct blow to the eye or a foreign body under the eyelid that irritates the corneal surface. These may be visible on gross exam, but often the lesion can only be seen on slit-lamp examination after staining with fluorescein dye. Similarly, corneal foreign bodies may be seen on visual inspection of the eye and should be suspected in any patient with eye pain associated with high-risk activities like use of power tools, grinding, hammering, or sanding objects with or without use of protective eyewear. If an object is visualized in the eye it should be flushed with saline or removed by a skilled practitioner unless there is concern that it has penetrated the globe, in which case the eye should be covered or patched and the object left in place until appropriate evaluation by a physician. Prehospital care of corneal injuries focuses on a thorough history, pain management, and transport to a center with appropriate specialty care. Most superficial corneal injuries heal within 24\u201372 hours, but the prognosis and potential for further complications depend on the depth and overall size of the lesion.",
        "Specific eye injuries - Retinal injuries": "Trauma of the retina and posterior segments of the eye is less common than injuries to anterior eye structures, but carries a higher risk of blindness and irreversible loss of vision. Common presentations include decreased visual acuity or a sensation of \u201cflashing lights\u201d or \u201cfloaters\u201d in the visual field of the affected eye. Retinal injuries require a complete fundus examination for definitive diagnosis, and these techniques are beyond the scope of this review. For the EMS physician, it is important to remember the signs of retinal and posterior segment injury and to obtain a focused eye history and examination, including visual acuity, before transporting the patient for ophthalmological evaluation and treatment."
    },
    {
        "Introduction": "A contemporary understanding of burn injuries is essential for all out-of-hospital providers. Burn injuries carry high morbidity and mortality, resulting in severe pain, scarring, and permanent disability. Additionally, specialized resources such as burn centers are required for care and recovery. Deaths from fires and burns are the third leading cause of fatal home injury. The US burn mortality rate ranks eighth among the 25 developed countries. According to the American Burn Association National Burn Repository 2012 statistics, over 450,000 victims received medical treatment for burns in the US in the last decade. The majority of these burns result from fire and/or flame injuries and contact with hot objects. Chemical burns account for approximately 3% of burns and 7% of burn admissions annually. Approximately 3,400 deaths occurred (most from smoke inhalation), including 2,550 deaths from residential fires (most from cooking), 300 from vehicle crash fires, and 550 from other sources (approximately 150 deaths from flame burns or smoke inhalation in non-residential fires, 400 from contact with electricity, scalding liquids, or hot objects). Although the number of fatalities and injuries from residential fires has declined gradually, many residential fire-related deaths remain preventable and pose a significant public health problem. Over 60% of US acute burn hospitalizations were admitted to 127 burn centers. Such centers each average over 200 annual admissions for burn injury and skin disorders requiring similar treatment. The other 4,500 US acute care hospitals average fewer than three burn admissions each per year. Fire and burn injuries represent 1% of the incidence of injuries and 2% of the total costs of injuries, or $7.5 billion each year. Risk factors for burn injuries include extreme age groups (<4 years and >65 years), poverty, African and Native American descent, and rural area dwellers.",
        "Pathophysiology": "Most adults have sustained burns during their lives. The skin is the largest organ in the body and serves as a barrier to outside insults and injuries. The skin protects against water loss, entrance of undesirable substances (microorganisms, toxins), mechanical shock and forces, extreme environmental temperatures, and ultraviolet light damage to keratin and melanin. Furthermore, the skin is involved in sensory perception, temperature regulation, and biochemical activities (e.g. vitamin D synthesis). The skin is made up of three basic layers. The outer layer, the epidermis, is the thin outer layer of the skin which consists of the stratum corneum containing fully mature keratinocytes which produce fibrous proteins (keratins) that are continuously shed (prevents the entry of most foreign substances as well as the loss of fluid from the body), the keratinocyte layer containing living keratinocytes (squamous cells), and the basal layer, the deepest layer of the epidermis, containing basal cells (continually dividing and forming new keratinocytes). The middle layer of the skin, the dermis, contains blood vessels, lymph vessels, hair follicles, sweat glands, fibroblasts, and nerves. The dermis is held together by collagen, made by fibroblasts, and gives skin flexibility and strength. The dermis also contains pain and touch receptors. The subcutis is the deepest layer of skin and consists of a network of collagen and fat cells that aid in conserving the body's heat and protect the body from injury by acting as a \u201cshock absorber.\u201d",
        "Severity": "Accurate assessment of the burn patient and appropriate institution of early care are critical to optimal outcomes. Although burn size and depth are obvious factors in determining burn severity, the location (body part) of the burn, age of the patient, preexisting disease, and presence of trauma, including inhalation injury, may complicate treatment. Specific anatomical locations of burns often result in significant morbidity and mortality disproportionate to burn size (i.e. head, neck, hands, feet, perineum, and genitalia). Furthermore, patients <2 years or >50 years old are at higher risk of complications and death than the remaining population. In infants, thin skin, limited reserves, and high surface area-to-mass ratios contribute to this risk, whereas thinning skin and medical problems commonly associated with aging are major factors in older individuals. Young children are also at risk for burns caused by abuse. These injuries are most often scald burns from tap water, are deeper than those seen in the general pediatric burn population, and commonly involve the lower extremities, buttocks, and genitalia. Pediatric and elderly burns may often be an initial presentation of abuse and should be considered in the differential diagnosis. There are several ways to classify burns (depth, severity, and surface area).",
        "Depth": "Burn depth is a product of temperature, duration of exposure, and skin thickness, with depth being described in its relationship to total skin thickness. Most burns have areas that are of mixed depth, with deeper burns often occurring in areas of thinner skin. The older classification of describing \u201cdegrees\u201d of burn is not often used any more. Rather, the American Burn Association now uses the total body surface area and the severity (partial verses full thickness) of injury as a modern descriptor. The old descriptive terms are paired with the newer classification system in order to understand the changes. First-degree (superficial) burn injuries involve only the epidermis or topmost layer of skin and are recognized by their erythematous appearance and lack of blisters or skin separation. The classic first-degree injury is the sunburn or superficial scald burn from spills. These burns usually have morbidity restricted only to pain, and are therefore not classified into burn size. Second-degree (superficial or deep partial thickness) burn injuries involve the epidermis and part way through the dermis. Epithelial elements remain in the undestroyed dermal appendages and spontaneous healing usually occurs in 7\u201328 days. Second-degree burns are very painful and are usually blistered. Third-degree (full-thickness) burn injuries are those that extend through the dermis, destroying all epidermal and dermal elements. They may initially have blisters containing hemorrhagic fluid and/or dead tissue (eschar). The presence or absence of pain is an unreliable indicator of depth and severity.",
        "Burn size": "Accurate initial assessment of burn size is essential for optimal patient care. Burn size is expressed as total body surface area (TBSA) or body surface area (BSA), where approximately 1% of a patient\u2019s surface area is equal to the palmar surface of the patient\u2019s hand with the fingers closed. This measurement is most useful for small (<5% TBSA) or spotty burns. For larger areas, the rule of nines for adults provides a simple and rapid estimation of burn size in the adult. When calculating burn size using any method, first-degree burns are not counted and only the proportion of area with at least a partial-thickness burn is calculated. Thus, for an upper extremity to be considered 9% TBSA, the entire extremity from the shoulder to the finger tips must be burned at least to the blistering level. If only the posterior half of the upper extremity is burned, then burn size is considered to be 4.5% TBSA. Calculating pediatric burns is often challenging and can be inaccurate if the provider is not appropriately trained. The rule of nines has also been used for pediatric patients. However, the Lund and Browder classification can also be used to more precisely calculate the percentage of BSA burned by mapping the injured areas of the body on charts detailing age-appropriate measurements. This method identifies the different body proportions according to the age of the patient (with children having larger heads and smaller lower extremities than adults) and through dividing the body into smaller units, such as dividing the upper extremity into the upper arm, lower arm, and hand. Computer programs are now being used to estimate surface area calculations.",
        "Inhalation injury": "Inhalation injury is a complex set of pathophysiological reactions that occur from exposure to smoke and/or chemical products. Systemic and respiratory damage can result in significant morbidity and mortality as well as permanent dysfunction. When combined with thermal injury, inhalation injury increases pulmonary compliance and fluid requirements, and doubles mortality. Technically, injury is a misnomer, and inhalation injury is really the result of fluid shifts caused by external burns. These conditions do not necessarily imply pulmonary injury, because they also occur with scald and chemical burns. Edema formation in the posterior pharynx and glottic and subglottic areas associated with deep burns of the upper chest, neck, and lower face has the potential to occlude the upper airway. Tachypnea and stridor are often late signs and when absent are unreliable in ruling out airway injury. Airway injury is diagnosed by fiberoptic bronchoscopy. Early grading of inhalation injury severity is often inaccurate. The injury is basically a chemical burn from which resulting edema of the small airways creates distal microatelectasis and a clinical picture identical to acute respiratory distress syndrome. Lower airway or \u201csmoke inhalation\u201d injury is caused by the patient inhaling the products of combustion, often as a result of being in a confined space. Specific injuries resulting from specific toxins, cyanide and carbon monoxide, are discussed elsewhere in this text.",
        "Chemical burn": "A caustic or corrosive agent is a chemical capable of causing tissue and mucous membrane injury upon contact. These agents are generally made up of extreme pH values (<3 or >11). The American Burn Association National Burn Repository reported in 2012 that over a 10-year period, chemicals represented 3.3% of all burns in the US. The majority of these burns resulted from accidental exposure at work. Chemical burns have higher complication rates in the very young and old populations with the most common complications being cellulitis, pneumonia, and respiratory failure. Common household and industrial products that result in burns include hydrochloric acid, potassium hydroxide, sodium hydroxide, sulfuric and phosphoric acids, and many others. Hydrofluoric acid (HF) is a weak acid and requires special consideration and specific antidotes that are addressed in Volume 1, Chapter 46. Although the most commonly affected body areas are the face, eyes, and extremities, almost all fatalities are as a result of ingestion.",
        "Specific training requirements": "The central concepts for prehospital providers and EMS physicians caring for burn patients include the following. 1 Thorough training on a consistent, organized patient assessment algorithm that can be applied to all burn patients, regardless of injury severity, is foundational. It should provide hierarchical management that focuses on life threats, yet incorporates full, sequenced evaluation and integrated management options for actual and potential injuries. Frequent reassessments and ability to integrate information and recognize trends that require urgent intervention are essential. 2 Efficient, appropriate use of local resources (air evacuation, hazardous materials teams, specialized rescue units), and knowledge of hospital capabilities and destination policies (e.g. specialty burn care center) can improve patient outcomes in patients with significant injuries where time is of the essence. EMS systems should have policies and procedures to identify such patients and promote primary transport to the appropriate facility when available. This concept, pioneered by trauma systems, is now being extended effectively to non-trauma disease processes. 3 Proper use of spinal motion restriction, splinting, fluid resuscitation, and pain management to limit additional morbidity. Knowing how and when to properly use infrequent invasive procedures such as cricothyrotomy, needle thoracostomy, and escharotomy is essential for patient safety and care. 4 Recognition of a chemical exposure and proper use of protective equipment is essential in limiting exposure to bystander and health care personnel.",
        "Burn-specific patient assessment and care": "Burn-specific patient assessment and care. The mechanism of injury, while not entirely predictive of actual injury sustained, often alerts the astute clinician to potential injuries that may be encountered during the assessment and metrics  Management of burn patients. The importance of integration of local EMS and hospital resources, and tailoring guidelines to optimize patient care within these parameters, cannot be overemphasized. Newer telemedicine applications that allow concurrent assessment by EMS and receiving emergency physicians may facilitate triage and continuity of and expedited care at the receiving facility for a number of time-sensitive medical complaints, certainly including burn injuries. Burn management differs significantly from routine trauma care. Traumatic injuries occur in 5\u201315% of admitted burn patients. Evaluation and treatment of traumatic injuries take precedence over treatment of the burn, with the caveat that maintenance of body temperature, airway protection, and appropriate burn fluid resuscitation must be achieved. Distance to the destination burn or trauma center should influence the plan for airway management. If transport time is short (e.g. <10 minutes) and if able to achieve adequate oxygenation and ventilation with basic measures such as a face mask or bag-valve-mask ventilation, time should generally not be taken at the scene for endotracheal intubation (ETI), including pharmacologically assisted intubation. However, in patients with suspected inhalation injury or impending obstruction, prehospital personnel should consider immediate ETI. ETI can be particularly challenging in the burn victim due to altered mental status and/or combativeness, airway secretions or debris, and potential swelling and distortion of anatomy. The EMS provider must decide if the delay in transport due to placing an advanced airway in a specific patient and situation is clinically beneficial, specifically if it outweighs the potential risk to the patient from either deterioration due to the injuries or due to secondary complications that could occur if the airway cannot be secured in a timely manner. While orotracheal intubation is the preferred route, edema and debris in a burn patient\u2019s airway may require a cricothyrotomy to be performed as a last resort. Training EMS personnel in alternative airway techniques may be extremely useful for complicated airway management. Secure the tube with cotton umbilical ribbon. Do not use adhesive tape on the endotracheal tube or any other important device or tube in the burn patient. The patient will become very edematous, the skin will fall off, and the endotracheal tube will fall out if secured only with tape. If this happens, it is very difficult to reestablish the airway due to extensive airway edema. If the patient is not intubated, closely observe for early indicators of impending airway obstruction such as facial or tongue swelling or hoarseness, and intubate the patient if these signs appear. Careful monitoring of respiratory parameters including pulse oximetry, end-tidal carbon dioxide, ventilatory compliance, and circulation will provide trending that can alert the provider to developing complications in a critical patient. High-flow oxygen should be used in all patients who show signs of respiratory distress and/or hypoxia. Beta-agonists have been used in cases of inhalation injury resulting in increased oxygen delivery and decreased bronchospasm. Outcome prediction metrics based on currently available high-level non-invasive monitoring may help refine destination choices and in-hospital trauma management. Burn eschar on the chest may interfere with ventilation and if this is the case, chest escharotomy should be performed during this assessment. Those with burn injuries have higher fluid requirements than other trauma patients. However, prehospital personnel must avoid excessive fluid resuscitation that could paradoxically lead to worsening hemorrhage and/or pulmonary function. Fluid resuscitation is the cornerstone of early burn care. The microvascular structures beneath a burn wound develop increased permeability immediately after injury, resulting in capillary leakage. Capillary leak is roughly proportional to burn size and becomes hemodynamically significant in burns larger than 20% TBSA (10% TBSA in young children or elderly patients). The objective of resuscitation is to replace lost intravascular fluid with the minimal amount of fluid required to maintain normal bodily function. Guidelines in the current literature instruct providers to calculate predicted 24-hour fluid requirements and initial fluid rate based on formulas. Although there are multiple formulas for predicting the first 24 hours of fluid required in burn patients, two of the most advocated formulas are as follows. Modified Brooke. Initial 24 hours: no colloids. Ringer\u2019s lactated (RL) solution 2 mL/kg/% burn in adults and 3 mL/kg/% burn in children. Parkland Formula. Initial 24 hours: RL solution 4 mL/kg/% burn for adults and 3 mL/kg/% burn for children. RL solution is added for maintenance for children: 4 mL/kg/hour for children weighing 0\u201310 kg 40 mL/hour + 2 mL/hour for children weighing 10\u201320 kg 60 mL/hour + 1 mL/kg/hour for children weighing 20 kg or higher. A randomized study of adult, military burn patients comparing these two formulas demonstrated that the modified Brooke formula was successful in lowering fluid requirements without increased mortality. Another burn formula to simplify fluid delivery was also advocated in prehospital patients, labeled \u201cthe rule of 10.\u201d Estimate burn size (using the rule of nines) to the nearest 10% TBSA. Multiply that by 10 to calculate the initial fluid rate for patients weighing 40\u201380 kg. Increase fluid rate by 100 cc/hour for every 10 kg of body weight above 80 kg. Underresuscitation may result in renal failure, hypotension, and multiple organ dysfunction, whereas overresuscitation results in pulmonary and cardiac overload and excessive edema formation. The extremes of age are especially sensitive to misestimation of fluid needs. Resuscitation requires an accurate estimation of the time of burn, burn size, and measurement of patient weight. Factors that increase fluid requirements include inhalation injury, late initiation of resuscitation, deep burns, acute intoxication, and preexisting malnutrition. All burn formulas are only starting points in resuscitation. Individual changes to fluid administration rates must be made hourly (or half-hourly in infants and small children) based on urine output and vital signs. The best formula is the one used by the burn center to which the patient is being transferred. Regardless of the type and volume of fluid used in resuscitation of burn patients, awareness and prevention of hypothermia are essential in maintaining circulation. Hypothermia increases burn mortality. Administration of significant volumes of IV fluids at or below room temperature can exacerbate the problem. Preventing heat loss and providing warm fluids to a patient in need of volume resuscitation or rewarming can diminish this potential effect. Several commercially available fluid warmers have been studied. All wounds should be exposed for evaluation. In patients with extensive burns, overlying clothes and jewelry should be removed. These items may have melted onto the skin. If this is the case, the burn team may need to excise these items along with the burned skin. Jewelry may have to be cut off with wire cutters or similar devices. Decontamination from toxins and chemicals should also begin during this phase of assessment. Saturated clothing should be removed, powdered chemicals should be brushed off the skin, and the contaminated area(s) irrigated with copious amounts of water until the patient experiences a decrease in pain in the wound. The use of neutralizing solutions in treatment of chemical burns is not routinely recommended except for burns involving hydrogen fluoride. However, control of amount of strong neutralizing solution is the key difficulty. Chemical injuries to the eye are treated by forcing the eyelid open and flushing the eye with water or saline.",
        "Special considerations - Compartment syndrome": "Formation of edema beneath full-thickness (usually circumferential) burn eschar has the potential to occlude arterial inflow to the extremity or restrict chest motion and hence ventilation, resulting in respiratory failure. If available, Doppler signals should be followed; if not, check pulses, skin temperature, and capillary refill at regular intervals. Diminution of the signal or a change in its character may suggest compartment syndrome. Patients receiving massive amounts of fluid may also develop compartment syndrome. This results from an increase in the tissue pressure of an inexpandable compartment of the body. If compartment syndrome is suspected, decompression of the involved compartments with appropriate escharotomy and fasciotomy is indicated as soon as possible. Treatment with escharotomy may be performed in the prehospital setting with either local anesthesia or conscious sedation. Incisions are placed midaxially on the medial and lateral portions of affected extremities and on the midaxillary lines of the trunk connected by an inverted \u201cV\u201d (chevron) incision along the costal margins. Escharotomies of the fingers are seldom, if ever, required.",
        "Hydrofluoric acid burn": "Hydrofluoric acid is an aqueous solution of the inorganic acid of elemental fluorine and will dissolve anything that has glass or silica content. HF and related products may cause dermal, ocular, pulmonary, gastrointestinal, and systemic injury. When in contact with skin, HF dissociates into hydrogen ions and free fluoride ions. There may be a latent period before a clinically evident burn is apparent, dependent on the concentration of the acid and the length of time it is in contact with the skin. Fluoride ions penetrate tissues deeply, causing tissue damage and the potential for systemic toxicity depending on the HF concentration. In general, exposure to HF solutions of greater than 50% concentration results in immediate pain and tissue destruction. The skin appears blanched, and within 1\u20132 hours the dermal lines are obliterated by edema. Dermal contact with concentrations of 20\u201350% HF usually results in burns that develop within a few hours. Concentrations greater than 20% HF have a potential for serious toxicity regardless of the degree of surface area involved. Contact with solutions of less than 20% HF concentration results in dermal injury that usually develops within about 24 hours. The clinical presentation of exposure to strong HF solutions of greater than 20% begins with pain at the site that is characteristically intense and often described by patients as \u201cburning,\u201d \u201cdeep,\u201d \u201cthrobbing,\u201d or \u201cexquisite.\u201d Local erythema and edema may or may not be present initially, but later a pale, blanched appearance of the skin is apparent in more severe burns from concentrated HF (e.g. >50%). Extensive bullae and maceration of tissue may be seen. Gray areas may develop and progress to frank necrosis and deep ulceration within 6\u201324 hours.",
        "Guidelines for out-of-hospital management": "Guidelines for management of the burn patient should be focused on providing necessary interventions, together with rapid transport to the closest appropriate facility. Triage guidelines should also address burn/trauma patients who need different types of specialty care by identifying regional facilities with special capabilities such as pediatric trauma, burn care, hyperbaric therapy, and extremity replantation. Scene time should not be delayed while the provider waits for direct medical oversight. Patient outcomes are significantly better at burn centers than non-burn centers. Burn centers have teams of professionals dedicated to optimal burn care. The American Burn Association has established criteria for transfer of a patient to one of these centers.",
        "Special considerations - Pain management": "The prehospital environment exacerbates the typical challenges found in treatment of acute pain and has the additional obstacles of a lack of supplies and equipment, delayed or prolonged evacuation times and distances, devastating injuries, provider inexperience, and dangerous tactical situations. Studies have shown an increase in the incidence of chronic pain and posttraumatic stress disorder (PTSD) with failure to recognize and treat acute pain appropriately, as well as a reduction in PTSD incidence when pain is adequately managed, particularly with early use of ketamine.",
        "Requirements for transfer": "Patients with major burns (>20% TBSA) require IV access, preferably two large-bore peripheral lines. Catheters may be placed through the burned tissue. Central venous access should be avoided because of its high complication rate in the early postburn period when vasospasm, low flow, and a hypercoagulable state contribute to complications. A urinary catheter and a nasogastric tube are recommended for long or delayed transport. Use of ice on a burn wound is absolutely contraindicated because of the risk of a cold injury superposed on the burn. Continual efforts must be made to keep the patient warm. No burn debridement is required before transfer, and the burns should be wrapped in dry sterile or clean sheets or burn-specific water-based gel dressings, and further covered with warm blankets.",
        "Prevention": "The prehospital environment offers a unique \u201cteachable moment\u201d for clinicians to educate patients and their families about preventing burns in the future. Prevention programs and safety legislation have made substantial contributions to decreasing the incidence and severity of burn injury, especially for parents and school-age children. In addition, several initiatives are targeting vulnerable segments of the population for prevention efforts. Mothers with less than high school education who are younger than 20 years and have more than two children are at a much higher risk for fatal fire events. Although prevention initiatives are reaching increasing numbers of people, there is still the need for further education of the public and in particular those subsegments of the population at high risk for burn injury. Specific preventive recommendations are listed."
    },
    {
        "Disclaimer": "This chapter summarizes the National Panel Guidelines for Field Triage of Injured Patients Recommendations of the National Expert Panel on Field Triage, 2011, which has been published previously in Morbidity, Mortality and Weekly Report (MMWR); available at: www.cdc.gov/mmwr/pdf/rr/rr6101.pdf. The text is excerpted from the original publication of current recommendations. In addition, some background materials from an earlier iteration have been included for context; available at: www.cdc.gov/mmwr/PDF/rr/rr5801.pdf. In general, all original MMWR text has been excerpted verbatim with a few exceptions (e.g. edits for transition or conciseness that do not affect meaning or interpretation of the recommendations or existing literature). To subscribe to MMWR, visit www.cdc.gov/MMWR.",
        "Introduction": "In the United States, unintentional injury is the leading cause of death for persons aged 1-44 years. In 2008, injuries accounted for approximately 181,226 deaths in the United States. In 2008, approximately 30 million injuries were serious enough to require the injured persons to visit a hospital emergency department (ED); 5.4 million (18%) of these injured patients were transported by EMS.\n\nEnsuring that severely injured trauma patients are treated at trauma centers has a profound effect on their survival. Ideally, all persons with severe, life-threatening injuries would be transported to Level I or Level II trauma centers, and all persons with less serious injuries would be transported to lower-level trauma centers or community EDs. However, patient differences, occult injuries, and the complexities of patient assessment in the field can affect triage decisions. \n\nThe National Study on the Costs and Outcomes of Trauma (NSCOT) identified a 25% reduction in mortality for severely Injured adult patients who received care at Level I trauma centers rather than at non-trauma centers. Similarly, a retrospective cohort study of 11,398 severely injured adult patients who survived to hospital admission in Ontario, Canada, indicated that mortality was significantly higher in patients initially undertriaged to non-trauma centers (odds ratio (OR) 1.24; 95% confidence interval (CI) 1.10-1.40).",
        "History of the field triage decision schemes": "In 1976, the American College of Surgeons Committee on Trauma (ACS-COT) began publishing resource documents to provide guidance for designation of facilities as trauma centers and appropriate care of acutely injured patients. Before this guidance appeared, the typical trauma victim was transported to the nearest hospital, regardless of the capabilities of that hospital, and often with little prehospital intervention. The ACS-COT regularly revised the resource document, which included a decision scheme to provide guidance for the field triage of injured patients. During each revision, the decision scheme was evaluated by a subcommittee of ACS-COT, which analyzed the available literature, considered expert opinion, and developed recommendations regarding additions and deletions to the decision scheme. Final approval of the recommendations rested with the ACS-COT Executive Committee. Following its initial publication in 1986, the decision scheme was updated and revised four times: in 1990, 1993, and 1999. In 2005, the Centers for Disease Control and Prevention (CDC), with financial support from the National Highway Traffic Safety Administration (NHTSA), collaborated with ACS-COT to convene the initial meetings of the National Expert Panel on Field Triage. The panel comprises persons with expertise in acute injury care, including EMS providers and medical directors, state EMS directors, hospital administrators, adult and pediatric emergency physicians, nurses, adult and pediatric trauma surgeons, persons in the automotive industry, public health personnel, and representatives of federal agencies. During 2005 and 2006, the panel met to revise the decision scheme, and the end-product of that comprehensive revision process was published by ACS-COT in 2006. In 2009, CDC published a comprehensive review of the revision process and the detailed rationale for the triage criteria underlying the 2006 version of the decisions scheme as the \u201cGuidelines for field triage of injured patients: recommendations of the National Expert Panel On Field Triage\u201d (the guidelines). In 2011, the panel reconvened to review the guidelines in the context of recently published literature as well as the experience of states and local communities working to implement the guidelines and to make recommendations regarding any changes or modifications to the guidelines. A major outcome of the panel\u2019s meetings was the revision of the guidelines. In 2012, CDC published an update to the guidelines, including the rationale for modifications; this update was endorsed by multiple national organizations. ",
        "Accuracy of field triage": "The accuracy of field triage can be thought of as the degree of match between the severity of injury and the level of care. Sensitivity and specificity of screening tests are useful indicators of accuracy (Figure 39.3). Maximally sensitive triage would mean that all patients with injuries appropriate for Level I or Level II trauma centers would be sent to such centers. Maximally specific triage would mean that no patients who could be treated at Level III or Level IV centers or community EDs would be transported to Level I or Level II centers. Triage that succeeded in transporting only patients with high injury severity to Level I or Level II centers would maximize the positive predictive value (PPV) of the process, and triage that succeeded in transporting only patients with low injury severity to Level III, IV, or community EDs would maximize the negative predictive value (NPV).\n\nIn reality, patient differences, occult injuries, and the complexities of patient assessment in the field preclude perfect accuracy in triage decisions. Inaccurate triage that results in a patient who requires higher-level care not being transported to a Level I or Level II trauma center is termed undertriage. The result of undertriage is that a patient does not receive the specialized trauma care required. Overtriage occurs when a patient who does not require care in a higher-level trauma center nevertheless is transported to such a center, thereby unnecessarily consuming scarce resources. In the triage research literature, all of these measures (sensitivity, specificity, PPV, NPV, undertriage, and overtriage; see Figure 39.3) are used together with measures of association (e.g., odds ratios) to assess the effectiveness of field triage.\n\nAs with sensitivity and specificity applied to screening tests, reductions in undertriage usually are accompanied by increases in overtriage, and reductions in overtriage are accompanied by increases in undertriage. Because the potential harm associated with undertriage (i.e. causing a patient in need of trauma center care not to receive appropriate care) is high and could result in death or substantial morbidity and disability, trauma systems frequently err on the side of minimizing undertriage rather than minimizing overtriage. Target levels for undertriage rates within a trauma system range from 0% to 5% of patients requiring Level I or Level II trauma center care, depending on the criteria used to determine the undertriage rate (e.g. death and Injury Severity Score (ISS)). Target levels of overtriage vary (approximate range: 25\u201350%). As field triage continues to evolve on the basis of new research findings, overtriage rates might be reduced while maintaining low undertriage rates.",
        "Field triage decision scheme recommendations": "Step one: physiological criteria Step one of the decision scheme seeks to guide EMS personnel in identifying critically injured patients rapidly through measuring their vital signs and assessing their level of consciousness. The instruction \u201cmeasure vital signs and level of consciousness\u201d has been included since the 1986 version of the ACS Field Triage Decision Protocol. The sensitivity of physiological criteria to identify severely injured patients has been reported to range from 55.6% to 64.8%, with PPV of 41.8% and specificity of 85.7%. A study of 333 patients transported by helicopter to a Level I trauma center during 1993 and 1994 indicated that physiological criteria alone were specific (0.9) but not sensitive (0.6) for identifying ISS >15. An evaluation of data in the South Carolina EMS registry, conducted to determine undertriage and overtriage rates when EMS personnel used the 1990 version of the ACS field triage guidelines, determined that physiological criteria alone had a sensitivity of 0.65 and PPV of 42% for severe injury (ISS >15) for 753 trauma patients transported to a Level I trauma center in Charleston. Adults meeting such physiological criteria treated at Level I trauma centers had reduced odds of mortality compared with patients treated at lower level trauma centers and non-trauma center hospitals (OR 0.7; 95% CI 0.6\u20130.9). Multiple peer-reviewed articles published since 2006 continue to support the use of physiological criteria. Transport is recommended to a facility that provides the highest level of care within the defined trauma system if any of the following are identified: \u2022 Glasgow Coma Scale \u226413, or \u2022 SBP <90 mmHg, or \u2022 respiratory rate <10 or >29 breaths per minute (<20 in infant aged <1 year), or need for ventilatory support.\n\nStep two: anatomical criteria: Step two of the guidelines recognizes that certain patients, on initial presentation to EMS providers, have normal physiology but have anatomical injuries that might require the highest level of care within the defined trauma system. In these cases, reliance on physiological criteria alone might lead to undertriage. In the South Carolina study noted above, the physiological criteria alone had a sensitivity of 0.7 and PPV of 42% for severe injury. Anatomical criteria alone had a sensitivity of 0.5 and PPV of 21.6%. Combining anatomical and physiological criteria to identify severely injured trauma patients produced a sensitivity of 0.8 and PPV of 26.9%. A prospective study of 5,728 patients treated by EMS providers in Washington state included patients who were injured and met at least one of the ACS triage criteria; patients were tracked from EMS contact through hospital discharge. Triage criteria were examined individually and in combination for their ability to identify a major trauma victim (MTV) with ISS of >15 or mortality. Anatomical criteria had a 20-30% yield for identifying major trauma victims and were associated with a hospital admission rate of 86% and a mortality rate slightly below that of the entire study population.\n\nTransport is recommended to a facility that provides the highest level of care within the defined trauma system if any of the following are identified:\nall penetrating injuries to head, neck, torso, and extremities proximal to elbow or knee\nchest wall instability or deformity (e.g., flail chest)\ntwo or more proximal long bone fractures\n\nStep three: mechanism of injury criteria: An injured patient who does not meet step one or step two criteria should be evaluated in terms of mechanism of injury (MOI) to determine if there might be a severe but occult injury. Evaluation of MOI will help to determine if the patient should be transported to a trauma center. Although different outcomes have been used, recent studies have demonstrated the usefulness of MOI for field triage decisions. A retrospective study of approximately 1 million trauma patients indicated that using physiological and anatomical criteria alone for triage of patients resulted in undertriage, implying that using MOI for determining trauma center need helped reduce the problem of undertriage. Another study of approximately half a million patients determined that MOI was an independent predictor of mortality and functional impairment of blunt trauma patients. Among 89,441 injured patients evaluated by EMS providers at six sites, physiological and anatomical criteria identified only 2,600 (45.5%) of 5,720 patients with ISS >15 whereas MOI criteria identified an additional 1,449 (25.3%) seriously injured patients with a modest (10%) incremental increase in overtriage (from 14.0% to 25.3%). Transport is recommended to a trauma center if any of the following are identified: \u2022 falls: \u25cb adults: >20 feet (one story=10 feet) \u25cb children: >10 feet or 2\u20133 times the height of the child \u2022 high-risk auto crash: \u25cb intrusion, including roof: >12 inches occupant site; >18 inches any site \u25cb ejection (partial or complete) from automobile \u25cb death in same passenger compartment \u25cb vehicle telemetry data consistent with a high risk for injury \u2022 automobile versus pedestrian/bicyclist thrown, run over,or with significant (>20 mph) impact \u2022 motorcycle crash >20 mph.\n\nStep four: special considerations: In step four, EMS personnel must determine whether persons who have not met physiological, anatomical, or mechanism criteria have underlying conditions or comorbid factors that place them at higher risk of injury or that aid in identifying the seriously injured patient. Persons who meet step four criteria might require trauma center care. A retrospective study of approximately 1 million trauma patients indicated that using physiological and anatomical criteria alone for triage of patients resulted in a high degree of undertriage, implying that using special considerations for determining trauma center need helped reduce the problem of undertriage. Among 89,441 injured patients evaluated by EMS providers at six sites, physiological, anatomical, and mechanism of injury criteria identified 4,049 (70.8%) patients with ISS >15; step four identified another 956 (16.7%) seriously injured patients, with an increase in overtriage from 25.3% to 37.3%. Transport to a trauma center or hospital capable of timely and thorough evaluation and initial management of potentially serious injuries is recommended for patients who meet the following criteria: \u2022 older adults: \u25e6 risk for injury/death increases after age 55 years \u25e6 SBP <110 might represent shock after age 65 years; low-impact mechanisms (e.g. ground-level falls) might result in severe injury \u2022 children: should be triaged preferentially to pediatric-capable trauma centers \u2022 anticoagulants and bleeding disorders: patients with head injury are at high risk for rapid deterioration \u2022 burns: \u25e6 without other trauma mechanism: triage to burn facility \u25e6 with trauma mechanism: triage to trauma center \u2022 pregnancy >20 weeks \u2022 EMS provider judgment.",
        "Pediatric concerns": "No published data suggest that injured children, in the absence of physiological, anatomical, or MOI triage criteria, are at risk for negative outcomes solely on the basis of their age. The criteria in steps one, two, and three of the 2006 decision scheme are expected to identify nearly all seriously injured children. Therefore, the panel identified no specific age below which all injured children should be transported to a trauma center. However, children meeting the revised field triage criteria for transport to trauma centers in steps one through three of the decision scheme should be transported preferentially to pediatric-capable trauma centers. Recent studies indicate that organized systems for trauma care contribute to improved outcomes for children and that seriously injured children fare better in pediatric-capable trauma centers. Multiple reports document improved survival in pediatric-capable trauma centers, including data from the Pennsylvania Trauma Outcome Study registry that demonstrate absolute reductions in injury mortality ranging from 3.8% to 9.7% and improved functional outcomes (e.g. feeding and locomotion) when children aged <16 years with ISS of >15 are treated at pediatric trauma centers or at adult trauma centers that have acquired additional qualifications to treat children. What appears to matter most is the availability of pediatric-specific resources, particularly the availability of a pediatric intensive care unit (ICU), not the designation as a pediatric trauma center per se. Although some earlier studies concluded that injured children treated in adult trauma centers had outcomes comparable to those of children treated in pediatric trauma centers, those investigations were conducted in hospitals with comprehensive pediatric services, including pediatric emergency medicine, critical care medicine, and nursing.",
        "Future research for field triage": "In its 2011 analysis, the panel noted an increase in the peer-reviewed published literature regarding field triage from the 2006 guidelines to the 2012 update. The 2011\u20132012 revision process identified and reviewed 289 articles published during 2006\u20132011 (~48 articles/year) directly relevant to field triage, 24 times the annual number of articles during 1966\u20132005 (~2/year) cited in the 2006 guidelines. Despite this increase in the number of articles, the panel concluded that ensuring that the guidelines are based on the best clinical evidence requires expanded surveillance, focused research using robust study designs, and consistent outcome measures. The preponderance of existing triage studies reviewed by the panel used retrospective data, trauma registry samples, single EMS agencies, and single trauma centers, all of which can result in biased estimates and reduced generalizability. Prospective triage research is needed that includes multiple sites, multiple EMS agencies, trauma and non-trauma hospitals, and population-based study designs that reduce selection bias and increase the generalizability of study findings. In addition, relatively little triage literature exists that evaluates the guidelines in their entirety (as opposed to an individual criterion or component steps of the decision scheme) and the contribution of each step to the full guidelines. Prospective studies evaluating the full guidelines among the broad injury population served by EMS are needed to assess the accuracy of the guidelines appropriately and to better identify targets for improvement. Further, the process of field triage in rural settings, including the effect of geography on triage, issues regarding proximity to trauma centers, use of air medical services, integration of local hospitals for initial stabilization, and secondary triage at non-trauma hospitals, is poorly understood. As a substantial portion of the US population lives >60 minutes from the closest major trauma center, and 28% of US residents are only able to access specialized trauma care within this time window by helicopter, field triage in non-urban environments needs to be understood better. Current peer-reviewed triage literature has described multiple outcome measures, including injury severity, clinical outcomes, need for trauma center resources (with or without a measure of timeliness), or a combination of these metrics. The most common clinical outcome measure is ISS >15, although the Abbreviated Injury Scale (AIS) \u22653 has also been used. Trauma center need has been measured by use of blood products, interventional radiology, major non-orthopedic surgery, or ICU stay. This variability in outcome measures limits comparability among studies and is not always consistent with literature identifying the subgroup of patients most likely to benefit from trauma center care. Future research should address these issues and attempt to match triage evaluation to patients most likely to benefit from trauma center care and clearly define the standard of measure. The issue of undertriage in older adults was viewed by the panel as a major priority for future research. There is a need to understand the basis for undertriage in this age group and how the guidelines might be modified to reduce this problem. Related topics include the role of age in predicting serious injury, different physiological responses to injury among older adults, different injury-producing mechanisms in older adults, attitudes and behaviors of emergency and trauma care providers regarding triage in older adults, older adults' health care preferences for injury care, end-of-life issues and their relevance to triage, new criteria to identify serious injury in older adults, the role of trauma centers in caring for older injured adults, and other aspects of better matching patient need with hospital capability for this population. How systems respond to patient and/or family preferences regarding hospital destinations that differ from the recommendations in these guidelines should be explored in the context of patients' rights and the moral imperative to provide the optimal chance for improved outcomes from trauma. Finally, the cost of trauma care, the implications of field triage on cost, and the cost-efficiency of different approaches to field triage require more research. Even after accounting for injury severity and important confounders, the cost of care is notably higher in trauma centers. Though the cost-effectiveness of trauma center care has been demonstrated among seriously injured patients (AIS \u22654), it is possible that modest shifts in overtriage might have substantial financial consequences. For example, a recent study that compared the 2006 and 1999 guidelines identified a potential $568 million cost saving at an assumed overtriage rate of 40%. However, further studies are needed to discover new ways to maximize the efficiency and cost-effectiveness of trauma systems and ensure that patients are receiving optimal injury care while considering the importance of the research, education, and outreach mission of trauma centers. Ongoing collaboration among local, state, and regional EMS agencies with governmental, non-governmental, academic, and public health agencies and institutions will allow the continuing analysis and evaluation of the 2011 guidelines and their effect on the care of acutely injured patients. State-wide EMS and trauma databases provide opportunities for state-wide quality improvement of field triage, research, and adaptation of the guidelines to meet state-specific circumstances. Large, nationally representative databases (e.g. the National EMS Information Systems database, the National Trauma Data Bank-National Sample Program, the Healthcare Cost and Utilization Project-National Inpatient Sample, the National Hospital Ambulatory Medical Care Survey, and NASS-CDS) could be used for future triage research if advances are made to link these data files across phases of care (e.g. prehospital to in-hospital). Finally uniform definitions of prehospital variables (including triage criteria) with a standardized data dictionary and data standards (e.g. HL7 messaging) could provide comparable data across study sites and assist with linking data files from the prehospital to the hospital setting.",
        "Conclusion": "The current field trauma triage guidelines are based on current medical literature, the experience of multiple states and communities working to improve field triage, and the expert opinions of the panel members. This guidance is intended to assist EMS and trauma systems, medical directors, and EMS physicians and providers with the information necessary to make critical decisions that have been demonstrated to increase the likelihood of improved outcomes in severely injured trauma patients. Improved field triage of injured patients can have a profound effect on the structure, organization, and use of EMS and trauma systems, the costs associated with trauma care, and, most importantly, on the lives of the millions of persons injured every year in the United States. As noted throughout this chapter, improved research is needed to assess the effect of field triage on resource allocation, health care financing and funding, and, most importantly, patient outcomes."
    },
    {
        "Introduction": "Uncontrolled hemorrhage is the second leading cause of death in the civilian trauma setting and the leading cause of preventable death during armed conflict. Traditional methods of hemorrhage control in the prehospital setting were simple dressings, direct pressure, proximal arterial pressure points, elevation of bleeding extremities, and, as a last resort, a tourniquet. These measures are essentially the same as those used in antiquity. Recent military and civilian experiences, as well as technological advances, have made new hemorrhage control tools available to both civilian and military out-of-hospital personnel.\n\nAdvances in civilian trauma care have often occurred secondary to military conflict. Because hemorrhage is the leading cause of potentially survivable death on the battlefield, researchers and physicians have focused intensely on prehospital management of severe hemorrhage. Within the past 10 years, significant advances have included several hemostatic dressings, ready-to-use tourniquets, and improved training in their use. Some of these experiences have directly translated into saved lives in the civilian setting as well.\n\nDeath from compressible hemorrhage is rare in civilian settings, being, in most instances, entirely preventable with simple first aid measures. Most civilian patients with severe hemorrhage can be rapidly transported to urban or suburban trauma centers while direct pressure is applied by a prehospital provider to an isolated injury. Hemorrhage control techniques commonly used by the military on the battlefield, such as tourniquets and advanced hemostatic agents, may have a role in EMS systems likely to encounter delayed patient transport, such as the rural and wilderness setting, prolonged extraction from a collapsed structure, enclosed space, or wrecked vehicle, and mass casualty incidents (MCI). This is particularly important in a scenario of mass shootings or deliberate bombings, where penetrating injury is the most common pattern and approximates battlefield situations.",
        "Assessment": "Traumatic hemorrhage is the acute loss of circulating blood volume as a result of injury. Hemorrhage severity is largely predicated on the volume of blood lost before hemostatic control can be achieved. This volume will vary as a function of vessel defect, vessel size, type, and location. Large defects result in not only greater bleeding but also greater consumption of clotting factors and platelets, increasing the likelihood of coagulopathy. Brisk, pulsatile bleeding and the bright red hue of oxygenated blood identify arterial hemorrhage. Arterial bleeding control will require the application of pressure sufficient to overcome the systolic blood pressure and compress the muscular wall of the vessel. Constant pressure for 20 or more minutes may be required to stop arterial bleeding. Venous bleeding is non-pulsatile, may be brisk if the vessel is large, and may appear darker until exposed to oxygen. Venous bleeding will occlude at much lower pressures, will require less time to control, and is more amenable to the use of hemostatic agents than arterial bleeding. Capillary bleeding is usually much less brisk than arterial or venous bleeding due to the smaller size of the involved vessels but may be difficult to control if the patient has platelet dysfunction or clotting factor deficiency.",
        "Diagnosis of hemorrhagic shock": "Hemorrhagic shock is a failure of the cardiovascular system to deliver oxygen and nutrients to tissues due to blood loss and hypovolemia. Hemorrhagic shock recognition has often depended on abnormalities of vital signs, appearance of the skin, urine output, and mental status. Although providing the basis of shock recognition and assessment, these metrics are limited by a number of important factors. Physiological response in patients on antihypertensives and other pharmacological agents is often blunted. Healthy patients in good physical condition may have sufficient physiological reserves to delay alterations in heart rate, blood pressure, and respiratory rate even with significant blood loss. Urine output can rarely be assessed in the prehospital environment and mental status, while sensitive to hypotension due to blood loss, can be clouded by concomitant head trauma, intoxication, hypoglycemia, pain medications, or mental illness.\n\nAlternative predictors of the severity of shock include the pulse pressure or shock index, both of which can be calculated from traditional vital signs. Pulse pressure is the difference between systolic and diastolic blood pressures. Use of pulse pressure in trauma is based on the principle that hemorrhage will increase the systemic vascular resistance, thus increasing diastolic pressure. At the same time, decreased preload will subsequently produce a reduction in systolic pressure. Narrowing of pulse pressure occurs before significant decreases in systolic blood pressure. Dynamic changes in pulse pressure have been used as a marker for cardiac output and volume status. Shock index is calculated by dividing the heart rate by the systolic blood pressure and has been shown to be more sensitive than either of the vital signs alone. Shock index predicts shock states in multiple trauma patients and is predictive of complications once patients are admitted to the hospital. It can also be adjusted to compensate for age-related differences in physiology, especially in the elderly.\n\nSerum lactate measurements may identify hypoperfusion; however, this is a late finding and may not be useful in a pre-hospital setting. Point-of-care testing of serum lactate, however, may be useful during long transports. A novel method for measuring and diagnosing shock is tissue oxygen saturation (which can be measured peripherally); however, it is still undergoing evaluation. Early laboratory studies show it to be an earlier marker than standard vital signs. Heart rate variability measurements are able to predict mortality but do not perform better than other common indices, and may not be the best for evaluation of hemorrhagic shock. Sublingual capnography theoretically recognizes local tissue hypoxia and microcirculatory injury, but recent studies suggest it is not present earlier than standard vital signs.",
        "Treatment modalities": "Pressure\nApplying direct pressure to stop bleeding from a wound is one of the most ancient principles of first aid. Steady, firm pressure using gauze or a large dressing (such as an abdominal pad) directly onto the bleeding site remains the method of choice to control hemorrhage in the civilian prehospital setting. The dressing must be of sufficient thickness so as not to diffuse or reduce the pressure applied to the site of hemorrhage. Once applied, pressure should be continued until the patient arrives at definitive care and is transferred to hospital personnel. The wound should not be periodically examined to see if the bleeding is stopped while en route, as this will result in disruption of the clot and rebleeding. Application of direct pressure requires the full attention of one provider.\n\nIf there are multiple casualties or the provider is unable to apply continuous pressure, a pressure dressing may be applied. Pressure dressings are effective and reliable for controlling hemorrhage. They can be fabricated with materials at hand, such as elastic bandages and cravats, or with ready-made commercial dressings. When applying a pressure dressing, the principles are essentially the same as when applying direct pressure. A large pledget of gauze should be applied directly to the wound and compressed with an elastic bandage or cravat. Pressure, not the dressing material itself, is the most important part of attaining hemostasis.\n\nTourniquets\nIf pressure fails to control hemorrhage from an extremity injury, a tourniquet should be applied. Initially used to curtail bleeding during amputation, the tourniquet was brought to the battlefield in 1674. Controversy and debate about the appropriateness and circumstances of tourniquet use began soon after and have continued through the current US conflicts in Iraq and Afghanistan. During the Vietnam conflict, Rich described only one case of limb loss secondary to tourniquet use among thousands of casualties with vascular injuries, and Hutton reported that fasciotomies were sometimes needed when tourniquet times were in excess of 2 hours.\n\nOver the course of the last decade, the controversy over tourniquet safety and effectiveness has subsided, with almost universal acceptance in severe extremity bleeding or amputation. Every US soldier and Marine carries a tourniquet, and it is used frequently on the battlefield. The most recent review of military use has shown that tourniquets are safe, effective, and have contributed to a significant reduction in deaths from extremity hemorrhage.\n\nCivilian prehospital studies evaluating tourniquet safety and effectiveness are lacking. Severe peripheral vascular injuries are relatively rare in the civilian setting and transport times to medical facilities are usually rapid. In most instances, civilian EMS providers can maintain continuous direct pressure on a bleeding injury until the patient arrives at the hospital. If direct pressure fails, a tourniquet should be applied. Tourniquets may be useful in MCIs related to explosive blasts, terrorism, or criminal violence. In these cases, there will often be more casualties than skilled providers, and evacuation from the scene may be delayed due to tactical concerns or because of collapsed and unstable structures. This was borne out during the Boston Marathon bombing in 2013. Based on bomb placement, a significant number of lower extremity injuries occurred. Early anecdotal reports conclude that the use of tourniquets (mostly field expedient) saved lives. The American College of Surgeons and the FBI consensus statement (the \u201cHartford Consensus\u201d) recommended tourniquets for life-threatening bleeding from extremity wounds during mass shooting scenarios. The Active Shooter Law Enforcement Rapid Response Training (ALERRT) Center, recognized by the FBI as the national training standard for active shooter response, also recommends the use of tourniquets for extremity hemorrhage.\n\nAs tourniquet use became the norm in a combat environment and extremity hemorrhage decreased as a cause of death, control of junctional hemorrhage (hemorrhage in potentially compressible areas not amenable to a standard tourniquet) could be initiated in the prehospital environment. Preliminary research into junctional tourniquets (initially, the Combat Ready Clamp in 2010) demonstrated their effectiveness and ongoing studies into other potential junctional tourniquet devices continue.\n\nThe abdominal aortic tourniquet, a device inflated over the abdomen with enough pressure to compress the abdominal aorta, is under investigation. A preliminary study demonstrated effectiveness in human volunteers where an abdominal tourniquet was used to reduce common femoral artery flow; however, it was extremely uncomfortable for the volunteers. Anecdotal evidence in the lay press suggests it may be useful and trials of this device are being conducted with selected groups of military personnel in Afghanistan.\n\nRapid wound closure\nSuturing and surgical stapling are common methods for hemorrhage control, but usually require time and clean fields. A novel device, recently introduced in the literature, the IT Clamp (Innovative Trauma Care, San Antonio, TX) looks like a hair clip and uses the teeth of the clip to grasp each side of the wound while the clamp portion closes over the wound, approximating the edges and allowing a hematoma to form to serve as a pressure dressing. An early study shows that it provides hemostasis in a swine groin injury model compared to standard gauze.\n\nElevation and arterial pressure points are no longer recommended as hemorrhage control methods because of insufficient evidence supporting their use.\n\nInternal occlusion\nAnother potential method for controlling hemorrhage that is being evaluated is the concept of reverse endovascular balloon occlusion of the aorta (REBOA). A balloon catheter is placed through the femoral artery into the aorta and inflated, occluding distal flow and stopping any bleeding distally, which could be extremely important in non-compressible bleeding, such as pelvic fractures. This technique, which effectively becomes an \u201cendovascular thoracotomy,\u201d has proven effective in a surgical and hospital setting, and in swine studies provides up to 90 minutes of occlusion without complications. Recently, researchers have demonstrated that the catheter can be placed in a prehospital setting, providing a potential opportunity to use this method for uncompressible hemorrhage not amenable to other techniques in a prehospital environment.",
        "Advanced hemostatic agents": "\n\nAdvanced hemostatic products to control bleeding have been developed for the prehospital environment. Ideally, a hemostatic agent would have the following properties for a prehospital environment.\n1 Approved or cleared by the US Food and Drug Administration\n2 Stops severe arterial and/or venous bleeding in 2 minutes or less\n3 No toxicity or side-effect\n4 Causes no pain or thermal injury\n5 Poses no risk to medics\n6 Ready to use with little or no training\n7 Durable and lightweight\n8 Flexible enough to fit complex wounds and easily removed without leaving residues\n9 Stable and functional at extreme temperatures (-10\u00b0C to +40\u00b0C) for at least 2 weeks\n10 Practical and easy to use under austere conditions (low visibility, rain, wind, etc.)\n11 Effective on junctional wounds not amendable to tourniquet\n12 Long shelf-life (>2 years)\n13 Inexpensive and cost-effective\n14 Biodegradable and bioabsorbable\n\nNumerous hemostatic agents have emerged into the marketplace in the last decade and this overview of hemostatic agents is not all-inclusive. Medical directors and EMS purchasing agents should become thoroughly familiar with the vast, confusing, and often contradictory literature regarding hemostatic agents before deciding to add them to their systems.\n\nFirst generation\nZeolite\nQuikClot (QC; Z-Medica, Wallingford, CT) is a granular zeolite powder that is FDA approved for external application in hemorrhage. QuikClot concentrates platelets, red blood cells, and clotting factors at the wound site through rapid adsorption of water. The reaction generates a significant amount of heat ranging from 68\u00b0C to 140\u00b0C. Initial studies demonstrated effectiveness in a large animal model with lethal groin injury; however, the injuries in these studies were different from those in follow-on studies and when compared against the more severe model (6 mm femoral arteriotomy), Quikclot failed to provide hemostasis. QC was initially fielded as a granular powder, but difficulty with application and the potential to be washed away by bleeding prompted a repackaging in gauze bags. Concerns with heat generation have led to a newer product called QuikClot ACS+ that uses synthetic zeolite beads in a cotton bag that produce minimal exothermic reaction.\n\nSecond generation\nCelox\nCelox (Medtrade Biopolymers, Crewe, UK) is a chitosan-based agent based on a proprietary granular mixture of different chitosan forms. Celox\u2019s primary mechanism is similar to that of chitosan in that it is mediated by a mixture of chemical and mechanical (adherence) linkages to red blood cells and tissues which form a physical barrier around the severed vessels. According to the manufacturer, this mechanism is not dependent on the coagulation factors of the patient. Celox is placed on top of a wound in a powder form, leading to the potential to be washed away if not secured to the wound. Attempts to place Celox in a gauze-like bag have been unsuccessful. In a comparison with other agents, it was shown to be inferior to Combat Gauze.\n\nCombat Gauze\nCreated by Z-Medica, Combat Gauze is an FDA-approved hemostatic agent consisting of ordinary cotton rolled gauze impregnated with kaolin, a fine clay-like material used in some antidiarrheal preparations. Kaolin appears to be a potent activator of the intrinsic clotting pathway, inducing the patient's own clotting factors to produce a clot. In a comparison between several other hemostatic dressings, including HemeCon and Celox-D, Combat Gauze proved to be the most effective and safest agent. This led to Combat Gauze being recommended by the Tactical Combat Casualty Care Committee (the US military\u2019s lead agency in guidelines for treatment of wounded service members) as the solitary hemostatic agent in 2009. Combat Gauze also has other factors that make it desirable as a hemostatic agent, including low cost, ease of use, and strong safety profile. See Video Clip 35.3 for application of Combat Gauze to a wound.\n\nThird generation\nCelox-XG\nCelox-XG Gauze (XG, SAM Medical Products, Wilsonville, OR) is also a chitosan-based product; however, instead of a powder, Celox-XG is a rolled fabric made with non-woven chitosan-derived hemostatic fibers. It works on the same principle as Celox but is much easier to apply than the powder form. It is the standard hemostatic agent for the United Kingdom military in Afghanistan. In one study, although outcomes were similar, Celox-XG did have shorter clot time than CG or standard gauze. In a more recent study, a comparison of CG, XG, and standard gauze showed less secondary blood loss and faster packing times for XG, but no differences in outcomes. The benefits of Celox-XG are comparable to Combat Gauze, including ease of use and strong safety profile.",
        "Adjunctive therapy": "Permissive hypotension\nMany studies suggest that limiting prehospital resuscitation protocols to achieve mean arterial pressures in the 60s may improve outcome over standard therapy designed to maintain systolic blood pressures of 100. This \u201cpermissive hypotension\u201d is thought to be sufficient to provide adequate perfusion to vital organs without exacerbating bleeding through clot dislodgment or dilution of clotting factors. Multiple studies have shown that permissive hypotension is also beneficial by limiting exposure to crystalloids and fractionated blood products. Crystalloid fluids have been demonstrated to dilute clotting factors and induce inflammatory cascades, which may result in increased hemorrhage and decreased survival. Current Tactical Combat Casualty Care guidelines for the US military also reflect this concept of giving colloid fluids only if there is a weak or absent peripheral pulse or altered mental status.\n\nPrevention of hypothermia\nModerate and severe hypothermia (body temperature of less than 32\u00b0C) inhibit coagulation and contribute to ongoing hemorrhage. Hypothermia reduces the enzymatic activity of coagulation proteins and inhibits the activation of platelets. Dysfunction of the coagulation system is evident below temperatures of 35\u00b0C, and temperatures below 30\u00b0C result in a 50% reduction in platelet function. As part of the \u201clethal triad\u201d of trauma (acidosis, hypothermia, coagulopathy), it can be avoided by using warmed fluids if possible and using blankets to keep patients warm, especially for longer transports. There are several commercially available hypothermia prevention kits.\n\nTransfusion\nTreatment with blood products in the prehospital environment is currently limited to specialized teams and air medical providers. There are trials of using blood product transfusion (plasma and packed red cells) from point of injury care for the US military in Afghanistan, and thus far there have been no known transfusion reactions. Most prehospital providers resuscitate with uncross-matched packed red blood cells, which lack platelets and clotting factors, which may support hemorrhage control. Recent studies of patients requiring massive transfusions have demonstrated that transfusion of platelets and plasma in conjunction with packed cells leads to better hemostatic control, decreased transfusion volumes, and greater survival. Military providers use whole blood before definitive hemorrhage control for similar reasons. Patients with life-threatening hemorrhage should be transfused before or during transport when blood products are available. Although cross-matched blood products are preferable, uncross-matched blood is often all that is available in emergency circumstances.\n\nFreeze-dried plasma (commonly referred to as lyophilized plasma) was originally developed in the United States during World War II. Falling out of favor in the US, it continued to be used successfully by the French military (with some interruption due to HIV transmission concerns). Use of lyophilized plasma in a prehospital setting would be advantageous in several scenarios, such as MCIs, long transports, or remote locations where access to other blood products might be difficult.\n\nMedications\nRecombinant factor VIIa (Novoseven)\nFactor VIIa is part of the extrinsic pathway in the coagulation cascade and initiates thrombin generation (activated factor Xa). It is licensed for the treatment of hemophilia patients with antibodies to factor VIII but is also used for the treatment of trauma victims with life-threatening hemorrhage. Boffard demonstrated that administration of factor VIIa reduced the need for packed red blood cell (PRBC) transfusion and massive transfusion in severely bleeding blunt trauma patients. Factor VIIa has not been demonstrated to reduce mortality or critical complications. Furthermore, it has been linked to complications including increased incidence of adult respiratory distress syndrome and is exceptionally expensive. In a more recent Cochrane review, the recommendation was that factor VIIa be used only in its FDA-approved indications unless under a study protocol.\n\nTranexamic acid (TXA)\nIntravenous administration of TXA was approved by the FDA in 1986 for prevention or reduction of bleeding in hemophilia patients undergoing dental procedures. Its mechanism of action is an antifibrinolytic that inhibits both plasminogen activation and plasmin activity, thus preventing clot breakdown rather than promoting new clot formation. In the CRASH-2 study, trauma patients were given TXA or placebo with a small but significant reduction in all-cause and bleeding mortality, with the highest improvements in those given TXA in the first 3 hours and in the most severely injured subgroups, as well as a very low incidence of harm. Studies in a combat environment showed similar benefits. Given its low cost, low incidence of adverse events, and importance of early administration, TXA administration may become a useful prehospital intervention.",
        "Conclusion": "Uncontrolled hemorrhage is a leading cause of preventable death. Direct pressure remains the primary treatment for hemorrhage and is sufficient for most wounds. Patients who fail management with direct pressure require immediate hemorrhage control. Extremity wounds can be controlled with tourniquets, while advanced hemostatic agents can treat wounds of the trunk and neck, and those in cavities. These agents are now capable of stopping even brisk arterial bleeding and have been shown to improve patient survival. In situations of prolonged transport time or austere environments, consideration should be given to adjunctive therapies such as hypotensive resuscitation, maintenance of euthermia, and transfusion of blood and blood products to address coagulopathy. As has been proven in recent mass casualty incidents such as the Boston Marathon bombing, EMS providers must be prepared to deal with exsanguinating hemorrhage on multiple patients that can parallel battlefield scenarios."
    },
    {
        "Introduction": "The major paradigm within EMS for penetrating trauma is the rapid transport of patients to definitive surgical care \u2013 a \u201cload and go\u201d strategy. Prehospital interventions that may delay transport should be reserved only for truly immediate life-threatening injuries identified on the primary survey. Note the survey should assess for cavitation, or the rapid expansion and contraction of tissues from the shock wave of the penetrating object.",
        "Epidemiology and General Principles": "Penetrating trauma in the United States: \u2219~ 20% of trauma \u221940-50% of all trauma mortality \u2219More likely to cause mortality in the first 72 hours vs. blunt trauma",
        "Out-of-Hospital Management": "Penetrating trauma patients are assessed using \u201cCABC,\u201d or Catastrophic Hemorrhage, Airway, Breathing, Circulation. C - CATASTROPHIC HEMORRHAGE Massive external hemorrhage is the first priority in management, with direct pressure being the mainstay of treatment. Prior to riding along, be familiar with the different bandages and supplies carried on board for hemostasis.",
        "Tourniquets": "Tip: After tourniquet application, it is normal to see some oozing but not frank arterial spray. Rapid exsanguination from penetrating isolated extremity trauma accounts for up to 10% of exsanguination deaths. \u2219Three-quarters of such wounds will be in the lower extremities. \u2219The majority are proximal to the knee or elbow. Tourniquets improve mortality. Properly used tourniquets: \u2219Do not increase permanent neurovascular injury. \u2219Do not change ultimate extent of amputation required.",
        "Application Principles": "\u2219Place 2 or more inches proximal to the point of injury. \u2219Device should be wide: \u2219Lower extremity bleeding is difficult to control with tourniquets less than 1 inch wide. \u2219Increased width may also reduce local tissue damage and complication. \u2219Device should be tightened until bleeding stops. \u2219Clearly document application time on device. \u2219Failure to control bleeding, or loss of previously controlled bleeding, should prompt placement of a second tourniquet more proximal to the first. \u2219Note: The first device should not be loosened or removed.",
        "Topical Hemostatic Agents": "Uncontrolled hemorrhage accounts for up to 80% of early civilian trauma deaths; a small percentage of these are from isolated extremity injury. Most of the civilian trauma hemorrhage is due to liver and cardiac injuries, with almost one-third involving a major vessel injury. Topical hemostatic agents are an option for wounds not amenable to tourniquets. These products can be used to rapidly pack penetrating wounds with pulsatile bleeding; in such cases, the source of the bleeding should be visible or accessible with a finger (eg, very proximal femoral artery injuries over the groin, abdominal injuries, etc.).",
        "Tranexamic Acid": "\u2219Tranexamic acid (TXA) may be of benefit for patients at risk for significant internal bleeding, especially if time to definitive care is delayed. TXA is a lysine derivate that prevents plasmin and plasminogen activity, thus reducing clot dissolution. Two major studies show roughly 10% mortality reduction (penetrating and blunt trauma combined). TXA is often given as bolus, followed by infusion: \u22191g over 10 min, then 1g over 8 hrs; best results if given within 3hrs of injury. It is always important to consider the mechanism, patient\u2019s vital signs, and overall clinical scenario prior to administration. \u2219Complications potentially include coagulant phenomenon such as MI, PE/DVT; however early studies have not shown increase in mortality from use. TXA\u2019s role in civilian EMS remains unclear; it is just starting to be integrated into many EMS systems."
    },
    {
        "Introduction": "At 08:15, paramedics are called to the scene of a construction site on a major highway, where a 36-year-old male has been crushed against the median by a semi-truck. Access to the site is complicated by block-age of 2 of the highway\u2019s 3 lanes during morning rush hour traffic. Police have secured the scene, and traffic is stopped. The semi-truck has been moved away from the scene. On arrival, the patient is lying face-up on the asphalt, minimally responsive and surrounded by his concerned, shouting co-workers. His breathing is severely labored, and there is blood coming from his mouth. He is moaning, his face and neck are purple, and he has obvious fractures of both legs. The foreman knows little about the patient\u2019s health other than he\u2019s a smoker and rarely misses work. No one has been able to contact the patient\u2019s wife, but efforts are continuing.",
        "Scene Safety": "Local law enforcement, fire, and EMS will be first to the scene of a motor vehicle collision (MVC). Before addressing the victims of the crash, it is essential the scene be assessed for safety. You must also anticipate any potential risks, including: \n141 Chapter 18: MVC \u2219Weather \n \u2219Flooding Fire/gasoline \n \u2219Chemical Spills \n \u2219Power lines \n \u2219Traffic \n \u2219Onlookers Traffic should be rerouted and the scene blocked off before assessment can begin. EMS should wear appropriate protective and reflective gear that allows for full body movement. Once the scene is secure, triage and stabilization for transport can begin. Fire will begin extricating victims trapped in vehicles. Be mindful of maintaining C-spine precautions when appropriate. Remain Alert to Your Surroundings at all Times",
        "Initial Assessment": "In an MVC, the speed of the vehicles involved, ejection of pas-sengers, the use of restraints, and need for extrication all can affect severity of injury.1 Recall Newton\u2019s Laws of Motion. Rapid deceleration, crushing, and ejection all produce significant forces on the body both internally and externally. Assessment of the patient should proceed with mechanism of injury in mind. (Table 1.)",
        "REMEMBER YOUR ABCs": "Initial assessment of the patient at the scene is ABC: A \u2013 AIRWAY: Ask a simple question, such as \u201cCan you tell me your name?\u201d If they do not respond, are there signs of obstruc-tion or noisy breathing? Jaw-thrust to open the airway. Try repo-sitioning if needed. If the jaw-thrust doesn\u2019t work, use the head tilt\u2013chin lift method.4 Use suction as needed. If the airway is clear, can the patient maintain it on his or her own? If not, insert an airway adjunct. Take care with patients with facial fractures, as the airway may be harder to manage. Maintain spinal precau-tions where possible. Avoid over-extension of the neck during ventilation and intubation4 and place a C-Collar where indicated.",
        "B \u2013 BREATHING": "If the patient is responsive but not breath-ing adequately, give high-flow oxygen and be prepared to help ventilate if needed. If the patient is unresponsive and breathing adequately, place the appropriate adjunct or assess for intuba-tion. Give high-flow oxygen. If the patient is unresponsive and not breathing adequately, place an adjunct and provide ventila-tion with a bag-valve-mask (BVM) device using high-flow oxygen. Any signs of inadequate breathing should prompt an immediate examination of the chest.",
        "C \u2013 CIRCULATION": "A patient who is responsive and/or breathing adequately will likely have an intact pulse. Check the radial for at least 5 seconds. If you cannot feel a pulse, check the carotid site. If any doubt exists, begin compressions and priori-tize transport. If a pulse is present, how is your patient\u2019s overall perfusion? Look for major bleeding and control it. Assess the patient\u2019s skin, noting color and condition. If the patient is a child, use the brachial site to check a pulse. Check capillary refill. It should be less than 2 seconds in adults and children.",
        "Injuries that Indicate a Priority Patient": "Certain mechanisms of injury indicate a priority patient, no matter how minor the injuries seem to be. Regardless of injury, any patient who has been fully or partially ejected from a ve-hicle, was in the same vehicle as someone who died, or was in the path of significant intrusion should be considered a priority patient. Pedestrian, bicyclists, and motorcyclists with an impact speed over 20 mph also fall into this category. Also consider age; the very young and very old are unable to compensate and may deteriorate quickly with seemingly minor injuries.",
        "Transport": "Once en route, EMS notifies the receiving transfer center/ED of basic details: \u2219Patient age and sex \u2219Mechanism of injury \u2219Vital signs \u2219Apparent injuries \u2219IV access \u2219Interventions performed: intubation, needle thoracostomy Early notification enables emergency department staff to pre-pare for the patient\u2019s needs: \u2219Notifying additional teams (eg, trauma surgery, orthopedics, neurosurgery, obstetrics) \u2219Anticipate procedures (eg, intubation, chest tube, thoracotomy)",
        "REASSESS THE PATIENT FREQUENTLY; PATIENT STATUS CHANGES QUICKLY": "While in transit, a paramedic notices the patient has stopped moving, and pulse oximetry is now declining. The blood pressure cuff is currently cycling. While there is a tracing on the monitor, a carotid pulse check reveals PEA arrest. The paramedic alerts the team, and CPR is initiated at 8:47 as EMS arrives at the ED. CPR continues as the patient is wheeled into the trauma bay.",
        "Conclusion": "Once at the ED, information should be communicated to the receiving staff or trauma team leader in a clear and succinct manner. In addition to any history obtained, the following should be included if applicable: \u2219Seat belt use \u2219Steering wheel deformation \u2219Airbag deployment \u2219Direction and speed of impact \u2219Damage to the vehicle (especially intrusion) \u2219Distance ejected \u2219Height of fall \u2219Body part landed upon \u2219Death of other passengers Assessment begins anew by the receiving team even during the handoff. Reassessment is essential in blunt trauma, as the variety of injuries can manifest in countless ways. Stability of the patient is dependent upon the vigilance of the treatment team. Clear communication and the maintenance of a calm environ-ment facilitate successful treatment in critical trauma situations."
    },
    {
        "KEY TERMS": "Abrasion: The most common type of open wound; characterized by skin that has been rubbed or scraped away., Amputation: The complete removal or severing of an external body part., Avulsion: An injury in which a portion of the skin, and sometimes other soft tissue, is partially or completely torn away., Burn: An injury to the skin or other body tissues caused by heat, chemicals, electricity or radiation., Chemical burn: A burn caused by strong, caustic chemicals damaging the skin., Closed wound: A wound in which soft tissue damage occurs beneath the skin and the skin is not broken., Compartment syndrome: Condition in which there is swelling and an increase in pressure within a limited space that presses on and compromises blood vessels, nerves and tendons that run through that limited space; usually involves the leg, forearm, arm, thigh, shoulder or buttock., Critical burn: Any burn that is potentially life threatening, disabling or disfiguring; a burn requiring advanced medical care., Crush injury: An injury to a body part, often an extremity, caused by a high degree of pressure; may result in serious damage to underlying tissues and cause bleeding, bruising, fracture, laceration and compartment syndrome., Dermis: The deeper layer of the skin; contains the nerves, sweat glands, oil glands and blood vessels., Electrical burn: A burn caused by contact with an electrical source, which allows an electrical current to pass through the body., Epidermis: The outer layer of the skin; provides a barrier to bacteria and other organisms that can cause infection., Full-thickness burn: A burn injury involving all layers of skin and underlying tissues; skin may be brown or charred, and underlying tissues may appear white; also referred to as a third-degree burn., Hypodermis: A deeper layer of skin located below the epidermis and dermis; contains fat, blood vessels and connective tissues., Laceration: A cut, usually from a sharp object, that can have either jagged or smooth edges., Open wound: A wound resulting in a break in the skin\u2019s surface., Partial-thickness burn: A burn injury involving the epidermis and dermis, characterized by red, wet skin and blisters; also referred to as a second-degree burn., Puncture/penetration: A type of wound that results when the skin is pierced with a pointed object., Radiation burn: A burn caused by exposure to radiation, either nuclear (e.g., radiation therapy) or solar (e.g., radiation from the sun)., Rule of Nines: A method for estimating the extent of a burn; divides the body into 11 surface areas, each of which comprises approximately 9 percent of the body, plus the genitals, which are approximately 1 percent., Soft tissues: Body structures that include the layers of skin, fat and muscles., Superficial burn: A burn injury involving only the top layer of skin, characterized by red, dry skin; also referred to as a first-degree burn., Wound: An injury to the soft tissues.",
        "INTRODUCTION": "An infant falls and bruises an arm while learning to walk; a child needs stitches in the chin after tumbling from the \u201cmonkey bars\u201d on the playground; a teenager gets a sunburn during a weekend at the beach; and an adult cuts a hand while working in a woodshop. What do these injuries have in common? They are all soft tissue injuries. In the course of growing up and in our daily lives, soft tissue injuries occur often and in many different ways. Fortunately, most soft tissue injuries are minor, requiring little attention. Often, only an adhesive bandage or a cold pack and rest are needed. Some injuries, however, are more severe and require immediate medical attention. Burns are a special kind of soft tissue injury. Like other types of soft tissue injury, burns can damage the top layer of skin or the skin and the layers of fat, muscle and bone beneath. In this chapter, you will learn how to recognize and care for soft tissue injuries.",
        "CRITICAL FACTS": "The skin is the largest organ in the body. The outer layer, called the epidermis, provides a barrier to bacteria and other organisms that can cause infection. An injury to the soft tissues is called a wound. Soft tissue injuries are typically classified as either closed wounds or open wounds.",
        "Soft Tissues": "The soft tissues include the layers of skin, fat and muscle that protect the underlying body structures. In Chapter 4, you learned that the skin is the largest single organ in the body and that, without it, the human body could not function. The skin provides a protective barrier for the body; it helps regulate the body\u2019s temperature and it receives information about the environment through the nerves that run through it. The outer layer of skin, the epidermis, provides a barrier to bacteria and other organisms that can cause infection. The deeper layer, the dermis, contains the important structures of the nerves, the sweat and oil glands, and the blood vessels. The hypodermis\u2014located beneath the epidermis and dermis\u2014contains fat, blood vessels and connective tissues. Because the skin is well supplied with blood vessels and nerves, most soft tissue injuries are likely to bleed and be painful. Beneath the skin layers lies a layer of fat. This layer helps insulate the body, to help maintain body temperature. The fat layer also stores energy. The amount of fat varies in different parts of the body and in each person. The muscles lie beneath the fat layer and comprise the largest segment of the body\u2019s soft tissues. Most soft tissue injuries involve the outer layers of tissue. However, violent forces, such as those that cause deep burns or cause objects to penetrate the skin, can injure all the soft tissue layers. Muscle injuries are discussed more thoroughly in Chapter 22, along with other musculoskeletal injuries.",
        "Types of Soft Tissue Injuries": "An injury to the soft tissues is called a wound . Soft tissue injuries are typically classified as either closed wounds or open wounds . A wound is considered closed when the soft tissue damage occurs beneath the surface of the skin, leaving the outer layer intact; this often results in internal bleeding. A wound is considered open when there is a break in the skin\u2019s outer layer; this usually results in external bleeding. Burns are a special kind of soft tissue injury. A burn injury occurs when intense heat, certain chemicals, electricity or radiation contact the skin or other body tissues. Burns are classified as superficial, partial thickness or full thickness.",
        "CLOSED WOUNDS": "Closed wounds occur beneath the surface of the skin. The simplest closed wound is a bruise, also called a contusion. Bruises result when the body is subjected to blunt force, such as when you bump your leg on a table or chair. Such a blow usually results in damage to soft tissue layers and blood vessels beneath the skin, causing internal bleeding. A much more serious closed wound can be caused by a violent force hitting the body. This type of force can injure larger blood vessels and deeper layers of muscle tissue, causing heavy bleeding beneath the skin, which causes a localized tissue mass that can be discolored by the internal bleeding. These injuries are referred to as hematomas.",
        "Signs and Symptoms of Closed Wounds": "When blood and other fluids seep into the surrounding tissues, the area discolors (turns black and blue) and swells. The amount of discoloration and swelling varies depending on the severity of the injury. At first, the area may only appear red. Over time, more blood may leak into the area, making the area appear dark red or purple. Violent forces can cause more severe soft tissue injuries involving larger blood vessels, the deeper layers of muscle tissue and even organs deep within the body. These injuries can result in profuse internal bleeding. With deeper injuries, you may or may not see bruising immediately.",
        "Providing Care for Closed Wounds": "Many closed wounds, such as bruises, do not require special medical care. To care for a closed wound, be sure to keep the injured area still. Applying cold can be effective early on in helping control both pain and swelling. When applying cold:\n\uf0a7 Make a cold pack by filling a sealable plastic bag with a mixture of ice and water, and then apply it to the injured area for about 20 minutes. Place a thin towel as a barrier between the cold pack and the bare skin. If an ice-and-water mixture is not available, use a bag of frozen vegetables or a chemical cold pack as an alternative. Do not place ice directly on a wound.\n\uf0a7 Remove the cold pack and wait 20 minutes before reapplying a new cold pack.\n\uf0a7 If the patient is not able to tolerate a 20-minute application, limit application to 10 minutes.\n\uf0a7 Elevating the injured part may help to reduce swelling; however, do not elevate the injured part if doing so causes more pain or you suspect a dislocation or fracture.\nDo not assume that all closed wounds are minor injuries. Take the time to find out whether more serious injuries could be present. With the cases that follow, the patient may be bleeding internally and need emergency medical care. Call for more advanced medical care if:\n\uf0a7 The patient complains of severe pain or cannot move a body part without pain.\n\uf0a7 The force that caused the injury seems great enough to cause serious damage.\n\uf0a7 An injured extremity is blue or extremely pale.\n\uf0a7 The patient\u2019s abdomen is tender and distended.\n\uf0a7 The patient is vomiting blood or coughing up blood.\n\uf0a7 The patient shows signs and symptoms of shock.\nWith all closed wounds, help the patient to rest in the most comfortable position possible. If you suspect the patient may be in shock, have them lie flat on their back and care for shock. In addition, keep the patient from getting chilled or overheated. Be sure that a patient with an injured lower extremity does not bear weight on it until advised to do so by a healthcare provider.",
        "OPEN WOUNDS": "In an open wound, the break in the skin can be as minor as a scrape of the surface layers or as severe as a deep penetration or even the loss of a body part. The amount of bleeding depends on the location and severity of the injury as well as other factors, including the patient\u2019s use of certain medications such as blood thinners or aspirin. Any break in the skin provides an entry point for disease-producing microorganisms, or pathogens.\nThere are six main types of open wounds, including:\n\uf0a7 Abrasions.\n\uf0a7 Amputations.\n\uf0a7 Avulsions.\n\uf0a7 Crush injuries.\n\uf0a7 Punctures/penetrations.\n\uf0a7 Lacerations.",
        "CRITICAL FACTS 2": "Burns are a soft tissue injury that has three classifications: superficial, partial thickness and full thickness.",
        "Abrasions": "An abrasion is the most common type of open wound. It is characterized by skin that has been rubbed or scraped away, such as when someone falls and scrapes their hands or knees. An abrasion is sometimes called a \u201crug burn,\u201d \u201croad rash\u201d or \u201cstrawberry.\u201d Because the scraping of the outer skin layers exposes sensitive nerve endings, an abrasion is usually painful. Bleeding is easily controlled and not severe, since only the capillaries are affected. Because of the way the injury occurs, dirt and other matter can easily become embedded in the skin, making it especially important to clean the wound.",
        "Amputations": "In some severe injuries, the force is so violent that a body part, such as a finger, may be severed. A complete severing of a part (usually involving a bone or limb) is called an amputation. Although damage to the tissue is severe, bleeding may not be as profuse as you might expect. The blood vessels usually constrict and retract (pull in) at the point of injury, slowing bleeding and making it relatively easy to control with direct pressure. In the past, a completely severed body part could not be successfully reattached. With today\u2019s technology, reattachment is often successful, making it important to carefully handle and send the severed part to the hospital with the patient.",
        "Avulsions": "An avulsion is an injury in which a portion of the skin and sometimes other soft tissue is partially or completely torn away. A partially avulsed piece of skin may remain attached but hang like a flap. Bleeding can be heavy because avulsions often involve deeper soft tissue layers.",
        "CRITICAL FACTS 3": "Open wounds are injuries that break the skin. These breaks can be as minor as a scrape of the surface layers or as severe as a deep penetration or even the loss of a body part. The six types of open wounds are abrasions, amputations, avulsions, crush injuries, punctures/penetrations and lacerations.",
        "Crush Injuries": "A crush injury is the result of a body part, usually an extremity, being subjected to a high degree of pressure, in most cases after being compressed between two heavy objects. This type of injury may result in serious damage to underlying tissues and cause bleeding, bruising, fracture, laceration and compartment syndrome . In a severe crush injury to the torso, internal organs may rupture. Crush injuries can be open or closed. Crush syndrome is common in people who are trapped in collapsed structures due to, for example, an earthquake or act of terrorism. The injury does not happen at the time that the tissue is crushed, but once the crushed muscle is released from compression and the tissue is re-perfused with blood. At that point, multiple adverse processes occur, as the products of muscle breakdown are released into the blood. The patient may suffer major shock and renal failure, and death may occur.",
        "Punctures/Penetrations": "A puncture/penetration wound results when the skin is pierced with a pointed object, such as a nail, piece of glass, splinter or knife. A bullet wound is also considered a puncture wound. Because the skin usually closes around the penetrating object, external bleeding is generally not severe. However, internal bleeding may be quite severe if the penetrating object damages major blood vessels or internal organs. An object that remains in the open wound is called an embedded object. An object may also pass completely through a body part, creating two open wounds\u2014one at the entry point and one at the exit point. Although puncture wounds generally do not bleed profusely, they are potentially more dangerous than wounds that bleed more, because they are more likely to become infected. Objects penetrating the soft tissues carry microorganisms that cause infections. Of particular danger is the microorganism that causes tetanus, a severe infection.",
        "Lacerations": "A laceration is a cut, usually from a sharp object. The cut may have jagged or smooth edges. Lacerations are commonly caused by sharp-edged objects, such as knives, scissors or broken glass. A laceration can also result when a blunt force splits the skin. Such splits occur in areas where bone lies directly under the skin\u2019s surface, such as the jaw. Deep lacerations can also affect the underlying layers of fat and muscle, damaging both nerves and blood vessels. Lacerations usually bleed freely and, depending on the structures involved, can bleed profusely. Because the nerves may also be injured, lacerations are not always immediately painful.",
        "Providing Care for Open Wounds": "With any open wound, always follow standard precautions to avoid contact with blood and OPIM.",
        "Providing Care for Open Wounds - Major Open Wounds": "A major open wound involves serious tissue damage and may bleed severely. As you learned in Chapter 19, the main priority of care for a major open wound is to control bleeding immediately with direct pressure using sterile dressings and pressure bandages and care for shock.",
        "Providing Care for Open Wounds - Minor Open Wounds": "In minor open wounds, such as abrasions, damage is only superficial and bleeding is normally minimal. To care for a minor open wound, follow these general guidelines:\n\uf0a7 Use a barrier between your hand and the wound. If readily available, put on disposable latex-free gloves and place a sterile dressing on the wound.\n\uf0a7 Apply direct pressure for a few minutes to control any bleeding.\n\uf0a7 Wash the wound thoroughly with soap and water and gently dry it with clean gauze. If possible, irrigate an abrasion for 5 minutes with clean, warm, running tap water.\n\uf0a7 Cover the wound with a clean dressing and a bandage (or with an adhesive bandage) to keep the wound moist and prevent drying. Apply an antibiotic ointment or wound gel to the dressing or bandage first if the patient has no known allergies or sensitivities to the medication. Do not apply the ointment or gel directly to the wound as doing so may contaminate the tube.\n\uf0a7 Wash your hands immediately after giving care, even if you wore gloves.",
        "CRITICAL FACTS 4": "With any open wound, always follow standard precautions to avoid contact with blood and OPIM.",
        "Providing Care for Open Wounds - Impaled Objects": "An impaled object is one that has been embedded into an open wound. There are two situations in which it is appropriate to remove an impaled object. The first is if the impalement is through the cheek, with uncontrolled bleeding and interference with airway management. The second is if the object impales the chest and interferes with CPR. When providing emergency care for an impaled object, securing the object is highly important so that it cannot move and cause further damage. Carefully secure the object manually, remove any clothing from the area if possible and control bleeding by applying direct pressure with sterile dressings to the edges of the wound. Avoid placing pressure on or moving the object. Once bleeding has stopped, apply a bulky dressing around the object, pack dressings around it and secure everything in place",
        "Providing Care for Open Wounds - Amputations": "In cases of amputation, first provide emergency care by controlling external bleeding. While it is important to care for the severed body part, it is vital to care for the patient first. Ask another responder to search for and provide care for the body part while you tend to the patient. If the amputation is incomplete (i.e., an avulsion), never remove the body part. Care for it as you would any soft tissue injury, stabilizing the part. If the body part is completely severed, find it, wrap it in sterile gauze, moistened in sterile saline if available. Then place it in a plastic bag, seal the bag, label it with the patient\u2019s name and the time and date it was placed in the bag. Keep the bag cool by placing it in a larger bag or container of an ice and water slurry, not on ice alone and not on dry ice.",
        "BURNS": "Burns are another type of soft tissue injury, caused primarily by heat. They can also occur when the body is exposed to certain chemicals, electricity or radiation. When burns occur, they first affect the top layer of skin, called the epidermis. If the burn progresses, the dermis, or the second layer, can also be affected. Deep burns can damage underlying tissues. Burns that break the skin can cause infection, fluid loss and loss of temperature control. They can also damage the respiratory system and eyes. The severity of a burn depends on the: \uf0a7 Temperature of the source of the burn. \uf0a7 Length of exposure to the source. \uf0a7 Location of the burn. \uf0a7 Size of the burn. \uf0a7 Patient\u2019s age and medical condition. In general, patients under 5 years of age and over age 60 have thinner skin and often burn more severely. People with chronic medical problems also tend to have more severe burns, especially if they are not well nourished, have heart or kidney problems, or are exposed to the burn source for a prolonged period because they are unable to escape.",
        "Classifying Burns": "Burns are classified in several ways, including their depth, their extent, whether or not there is respiratory involvement, the body part burned and the source (or cause): heat (thermal), chemical, electrical or radiation (such as from the sun).",
        "Depth of Burn": "Burns are classified by depth. The deeper the burn, the more severe it is. The three classifications of burns include superficial burns (formerly referred to as first degree), partial-thickness burns (formerly referred to as second degree) and full-thickness burns (formerly referred to as third degree).",
        "Superficial Burns": "A superficial burn involves only the top layer of skin, the epidermis. The skin is red and dry, and the burn is usually painful. The area may swell. Most sunburns are superficial burns. Superficial burns generally heal in 5 to 6 days without permanent scarring.",
        "Partial-Thickness Burns": "A partial-thickness burn involves both the epidermis and the dermis. These injuries are also red and have blisters that may open and weep clear fluid, making the skin appear wet. The burned skin may look mottled (blotchy). These burns are usually painful, and the area often swells. The body loses fluid, and the burn is susceptible to infection. Although the burn usually heals in 3 or 4 weeks, extensive partial-thickness burns can be serious, requiring more advanced medical care. Scarring may occur from partial-thickness burns.",
        "Full-Thickness Burns": "A full-thickness burn destroys both layers of skin as well as any or all of the underlying structures: fat, muscles, bones and nerves. These burns may look brown or charred (black), with the tissues underneath sometimes appearing white. They can be either extremely painful or relatively painless if the burn destroys nerve endings in the skin. Full-thickness burns are often surrounded by painful partial-thickness burns. Full-thickness burns can be life threatening. Because the burns are open, the body loses fluid, and shock is likely to occur. These burns also make the body highly prone to infection. Scarring occurs and may be severe. Many burn sites eventually require skin grafts.",
        "Extent of Burn": "The extent of a burn is another important aspect of the severity of the burn. It is commonly described using the Rule of Nines. This method is used in the field to quickly determine if patients need to go to a specialty burn center for treatment. It approximates the percentage of burned surface area of the patient. In an adult, the body surface is divided into the following 11 sections, each comprising approximately 9 percent of the body\u2019s skin coverage: \uf0a7 Head \uf0a7 Right arm \uf0a7 Left arm \uf0a7 Chest \uf0a7 Abdomen \uf0a7 Upper back \uf0a7 Lower back \uf0a7 Right thigh \uf0a7 Left thigh \uf0a7 Right leg (below the knee) \uf0a7 Left leg (below the knee) These body parts equal 99 percent, leaving the genitals to make up the last one percent. The Rule of Nines is applied by adding up all the areas of the body that have partial- or full-thickness burns. Partial areas are approximated. With pediatric patients, considerations must be made for the fact that the head is a proportionally larger contributor to body surface area and the upper legs contribute less. The pediatric Lund-Browder diagram reflects this difference. The patient\u2019s palm can be used to estimate the size of a patchy burn. Assume that the patient\u2019s palm represents approximately 1 percent of a body\u2019s total surface area. If you do not remember the Rule of Nines, simply communicate to more advanced medical personnel or the specialty burn center how the burn occurred, the body parts involved and the approximate type of burn. For example, \u201cThe patient was injured when an overheated car radiator exploded. The patient has partial-thickness burns on the face, neck, chest and arms.\u201d",
        "Respiratory Involvement": "The respiratory system may also be damaged when a patient is burned. If you note soot or burns around the mouth, nose or the rest of the face, this may be a sign that air passages or lungs have been burned. Respiratory damage may include airway closure due to swelling of the face and throat. Consider a hoarse voice a sign of respiratory involvement. There may also be swelling of the larynx due to inhalation of superheated air, which may also cause fluid accumulation in the lungs. With more severe inhalation of smoke and toxic gases, there may be respiratory arrest or compromise, or poisoning. Burns around the chest can reduce the patient\u2019s ability to expand the chest. This can cause trouble breathing. Circumferential burns are also of concern. Circumferential burns refer to burns that circle an entire body part. Circulatory compromise in that extremity can be the result of a circumferential burn to an extremity. A circumferential burn to the chest is of critical concern because of expansion and contraction during respiration.",
        "Body Part Burned": "The particular part of the body burned also determines the seriousness of the burn. Burns to certain parts of the body are more critical than to others. In particular, burns to the head, face, eyes and ears may be associated with respiratory problems and may be disfiguring. Burns to the hands and feet are serious because of the potential impact on the patient\u2019s function. Burns to the genitals or groin area are considered critical because of the potential loss of function and because these areas are susceptible to infection. Burns in any area where there is a significant joint (e.g., hips and shoulders) are serious because of potential loss of joint function.",
        "Cause of Burn": "It is also important to take into account the source of the burn. Thermal burns include those caused by an open flame; contact with a hot object, steam or gas; or scalding by hot liquid. Burns can also be caused by chemicals, electricity and radiation. Expect that burns caused by flames or hot grease will require medical attention, especially if the patient is under 5 or over 60 years of age. Hot grease is slow to cool and difficult to remove from the skin. Burns that involve hot liquid or flames contacting clothing will also be serious, since the clothing prolongs the heat contact with the skin. Some synthetic fabrics melt and stick to the body. The melted fabrics may take longer to cool than the soft tissues. Although these burns may appear minor at first, they can continue to worsen for a short time.",
        "CRITICAL FACTS 5": "Consult with medical control for a decision on when to transport the patient involved in a burn incident. Advanced medical personnel must assist in the care of serious burn injuries, such as those causing difficulty breathing, burns covering more than one body part or to delicate body parts, any serious burns to a child or older adult patient, and any burns from chemicals, explosions or electricity.",
        "Severity of the Burn": "It is important to be able to identify a critical burn. A critical burn requires the immediate attention of more advanced medical personnel. Critical burns are potentially life threatening, disfiguring and/or disabling. Knowing whether you should summon more advanced medical personnel for a burn injury can sometimes be difficult. It is not always easy or possible to assess the severity of a burn immediately after injury. Even superficial burns to large areas of the body or to certain body parts can be critical. You cannot judge severity by the pain the patient feels, because nerve endings may have been destroyed. Consult with medical control for a decision on when to transport the patient. Call for more advanced medical personnel immediately for assistance in caring for the following: \uf0a7 Burns causing breathing difficulty \uf0a7 Signs of burns around the mouth and nose \uf0a7 Burns covering more than one body part \uf0a7 Burns to the head, face, neck, hands, feet or genitals \uf0a7Any partial-thickness or full-thickness burn to a child or an older adult Burns resulting from chemicals, explosions or electricity Patients should be referred to a burn unit if they have: Partial- or full-thickness burns that cover more than 10 percent of the body surface, for those patients under the age of about 5 or over about 60. Partial- or full-thickness burns that cover more than 2 percent of the body surface, for those in other age groups. Partial- or full-thickness burns that involve the face, hands, feet, genitalia, perineum or major joints. Full-thickness burns that cover more than 5 percent of the body surface, in patients of any age. Electrical burns, including injury caused by lightning. Chemical burns. Inhalation injury. Circumferential burns. A burn injury and a pre-existing medical condition that could make their care more complicated or lengthy, or that could affect mortality (e.g., diabetes). Both burns and other injuries (e.g., fractures or blast injury) where the burn injury poses the greatest risk of morbidity or mortality. A burn injury (in a child) and the hospital lacks qualified personnel or equipment. In this case, the child with burns should be transferred to a burn center with the required personnel and equipment needed to look after a child with burns. A burn injury (in a child) where there are special circumstances (e.g., suspected child abuse or substance abuse) and where social/emotional and/or long-term rehabilitative support will be needed.",
        "Signs and Symptoms of Thermal Burns": "The signs and symptoms of thermal burns depend upon the extent of the burn. The signs and symptoms, based on the degree of the burns, are as follows: Superficial burns. Painful, red area that turns white when touched; no blisters; moist-appearing skin Partial-thickness burns. There are two kinds of signs and symptoms\u2014superficial and deep: Superficial signs and symptoms: Painful, red area that turns white to touch; mottling, blisters, moist skin; hair is still present Deep signs and symptoms: May or may not be painful (nerve endings may be destroyed); may be moist or dry (sweat glands may be destroyed); may or may not turn white when area is touched; hair is usually gone Full-thickness burns. Painless, no sensation to touch, pearly white or charred, dry and may appear leathery",
        "Providing Care for Thermal Burns": "As you approach the patient, decide if the scene is safe. Look for fire, smoke, downed electrical wires and warning signs for chemicals or radiation. If the scene is not safe and you have not been trained to manage it, summon specially trained personnel. If the scene is safe, approach the patient cautiously. If the source of the burn is still in contact with the patient, take steps to remove and extinguish it. Doing so may require you to smother the flames or extinguish them with water or to remove smoldering clothing. For example, if the burn is caused by hot tar or plastic, cool the area with water but do not attempt to remove the tar or plastic. Perform a primary assessment. Pay close attention to the patient\u2019s airway. Note soot or burns around the mouth, nose and the rest of the face, which may be a sign that air passages or lungs have been burned. If you suspect a burned airway or burned lungs, continually monitor breathing and call for advanced medical personnel immediately. Air passages may swell, impairing or stopping breathing. Administer supplemental oxygen if it is available. As you do a physical exam, look for additional signs of burn injuries. Also look for other injuries, especially if there was an explosion or electrical shock. If thermal burns are present, once you have removed the patient from the source, follow these three basic care steps: 1. Cool the burned area. 2. Cover the burned area. 3. Minimize shock.",
        "CRITICAL FACTS 6": "To care for a thermal burn, remove the patient from the source, cool and cover the burned area, and take steps to minimize shock.",
        "Cool the Burned Area": "Even after the source of the burn has been removed, soft tissue will continue to burn, causing more damage. Therefore, it is essential to cool any burned areas immediately with large amounts of cool or cold running water for at least 10 minutes or until pain is relieved. Do not use ice or ice water. Ice or ice water can cause critical body heat loss and may make the burn deeper. Flush the area using whatever resources are available (e.g., a tub, shower or garden hose). You can apply soaked towels, sheets or other wet cloths to a burned face or other area that cannot be immersed. Be sure to keep these compresses cold by frequently resoaking them with cold water; otherwise, they will not absorb the heat from the skin\u2019s surface. Be careful to not cause hypothermia when cooling large burns or burns on small children, who are more prone to hypothermia than adults due to their greater skin surface area relative to their weight. Allow adequate time for the burned area to cool. If pain continues or if the edges of the burned area are still warm to the touch when the cooling source is removed, continue cooling. When the burn is cool, remove any remaining clothing from the area by carefully removing or cutting material away. Do not try to remove any clothing that is stuck to skin. Remove any jewelry only if doing so will not further injure the patient, as swelling may occur. In some jurisdictions, you may be provided more specific directions for when and how to cool burns. Follow your local protocols.",
        "Cover the Burned Area": "Burns often expose sensitive nerve endings. Cover the burned area to keep out air and help reduce pain. Use dry, sterile dressings, and loosely bandage them in place. The bandage should not put pressure on the burn surface. If the burn covers a large area of the body, cover it with clean, dry sheets or other clean cloths. Covering the burn helps prevent infection. Do not put ointments, butter, oil or other commercial or home remedies on any burn that will receive medical attention. These products seal in heat and do not relieve pain. Other home remedies can contaminate open skin areas, causing infection. Do not break blisters. Intact skin helps prevent infection. For small superficial burns or small burns with open blisters that are not sufficiently severe or extensive enough to require medical attention, care for the burned area as an open wound. Wash the area with soap and water. Cover the burn with a dressing and bandage. Apply antibiotic ointment or wound gel if your protocols permit you to do so, one is available, and the patient has no known sensitivities or allergies to the medication. Tell the patient to watch for signs of infection.",
        "Minimize Shock": "Full-thickness burns and large partial-thickness burns can cause shock as a result of pain and loss of body fluids. Have the patient lie down unless they are having trouble breathing. Administer supplemental oxygen based on local protocols and if it is safe to do so.",
        "Risk of Hypothermia": "Patients who have sustained a burn have an impaired ability to regulate the body\u2019s temperature. Therefore, there is a tendency to chill. Keep the patient warm to prevent hypothermia. Help the patient maintain normal body temperature by protecting the patient from drafts. Remember that cooling burns over a large area of the body also risks inducing hypothermia in the burned patient. Be cautious and aware of this risk when cooling a burn that covers a large area.",
        "Providing Care for Burn - Pediatric Considerations": "Providing Care for Burns Children have a larger body surface area relative to their weight than do adults. Body surface area is a major factor in determining how much water is lost through evaporation in burn patients. Therefore, children with burns lose more water through evaporation than do adult patients. This means that children usually tend to have greater fluid needs during resuscitation. Evaporative water loss leads to greater heat loss, so children or infants with burns are prone to hypothermia. Keep the room temperature high. When dealing with pediatric burn patients, be aware of the possibility that the burns are the result of child abuse. Inflicted burns often leave characteristic patterns of injury that cannot be concealed. A detailed history, including previous trauma, presence of recent illnesses and immunization records, will help determine if your suspicions are correct.",
        "Chemical Burns": "Chemical burns are common in industrial settings, but also occur in the home. Cleaning solutions, household bleach, oven or drain cleaners, toilet bowl cleaner, paint strippers, and lawn or garden chemicals are common sources of caustic chemicals that can eat away or destroy tissue. Caustic chemicals cause chemical burns. Typically, burn injuries result from chemicals that are strong acids or alkalis. These substances can quickly injure the skin. As with heat burns, the stronger the chemical and the longer the contact, the more severe the burn. The chemical will continue to burn as long as it is on the skin. You must remove the chemical from the skin as quickly as possible, and then call for more advanced medical personnel immediately. If you suspect a chemical burn, also check to see whether the eyes are burned.",
        "Signs and Symptoms of Chemical Burns": "Signs and symptoms of chemical burns include:\n\uf0a7 Pain.\n\uf0a7 Burning.\n\uf0a7 Numbness.\n\uf0a7 Change in level of consciousness (LOC).\n\uf0a7 Respiratory distress.\n\uf0a7 Oral discomfort or swelling.\n\uf0a7 Eye discomfort.\n\uf0a7 Change in vision.",
        "Providing Care for Chemical Burns": "Always brush dry or powdered chemicals off with a gloved hand or a cloth, if possible. If not, flush them off with water. In some cases, a continuous flow of water will remove a dry substance before the water can activate it. Continue flushing until more advanced medical personnel arrive or for at least 20 minutes. If the substance is a liquid, flush the burn continuously with large amounts of cool, running water until more advanced medical personnel arrive or for at least 20 minutes. Have the patient remove contaminated clothing and jewelry, if possible. Take steps to minimize shock. Chemical burns to the eyes can be exceptionally traumatic. Ensure more advanced medical personnel have been called. If an eye is burned by a chemical, flush the affected eye until more advanced medical personnel arrive or for at least 20 minutes. Flush the affected eye from the nose outward and downward to prevent washing the chemical into the unaffected eye. Be aware that chemicals can be inhaled, potentially damaging the airway or lungs. Call the national Poison Help line at 800-222-1222 if you believe chemicals have been inhaled and give that information to the call taker.",
        "Electrical Burns": "The human body is a good conductor of electricity. When someone comes into contact with an electrical source, such as a power line, a malfunctioning household appliance or lightning, electricity is conducted through the body. Body parts resist electrical current; some body parts, such as the bones, resist the electrical current more strongly than others. This resistance produces heat, which can cause electrical burns along the flow of the current.",
        "Signs and Symptoms of Electrical Burns": "The severity of an electrical burn depends on the type and amount of contact, the current\u2019s path through the body and how long the contact lasted. Electrical burns are often deep; although these wounds may look superficial, the tissues beneath may be severely damaged. Some electrical burns will be marked by entry and exit wounds indicating where the current has passed through the body. The signs and symptoms of electrical injury include:\n\uf0a7 Unconsciousness.\n\uf0a7 Dazed, confused behavior.\n\uf0a7 Obvious burns on the skin\u2019s surface. Trouble breathing or no breathing. \u2019 Burns both where the current entered and where it exited the body, often on the hand or foot.",
        "Providing Care for Electrical Burns": "Scene safety is of utmost importance. Once it is determined that the electrical current is secured and no longer passing through the patient, perform a primary assessment and care for any immediate life-threatening conditions. During the physical exam, look for two burn sites (entry and exit wounds). Cool any electrical burns with cool or cold running water as you would a thermal burn; then cover any burn injuries with a dry, sterile dressing, and provide care to minimize shock. Look for painful, swollen and deformed extremities, because the resistance to the electrical current can cause severe muscle contractions, which may produce musculoskeletal injuries. With someone who has been struck by lightning, look for and provide care for life-threatening conditions such as respiratory or cardiac arrest. The patient may also have fractures, including spinal fracture, so do not move the patient unless evacuation is required due to the scene becoming unsafe. Caring for any immediate life-threatening conditions takes priority over caring for burns. Exposure to high- or even low-voltage electric current can cause dangerous cardiac arrhythmias in addition to electrical burns. Be prepared to perform CPR and use an AED. Anyone who suffers an electrical shock needs an advanced medical assessment to determine the extent of injury.",
        "Radiation Burns": "Radiation burns may occur from exposure to nuclear radiation, X-rays or as a side effect of radiation therapy. It can also be caused by tanning beds, or as the result of solar radiation from the sun. Solar burns are similar to heat burns, often resulting in superficial and sometimes partial-thickness burns. Usually they are mild, but they can be painful. They may blister, involving more than one layer of skin. Care for sunburn as you would any other burn. Cool the burn and protect the burned area.",
        "PUTTING IT ALL TOGETHER": "Caring for wounds involves controlling bleeding and minimizing the risk of infection. Your primary concern with minor wounds is to clean the wound to prevent infection. For major wounds, control the bleeding quickly and summon more advanced medical personnel. Always use a barrier such as disposable latex-free gloves, dressings or a clean folded cloth, to avoid contact with blood. Dressings and bandages, when correctly applied, help control bleeding, reduce pain and minimize the risk of infection. Apply pressure to help stop bleeding. Burns damage the layers of the skin and sometimes the internal structures, which can be life threatening. Heat, chemicals, electricity and radiation all cause burns. When caring for someone who has sustained a burn, always ensure the scene is safe. Approach the patient and check for life-threatening conditions and for non-life-threatening conditions, if necessary. Once the patient has been removed from the burn source, follow the steps of burn care: \uf0a7 Cool the burned area with water to minimize additional tissue destruction. \uf0a7 Protect the burned area by covering it with sterile dressings, clean sheets or other cloth. \uf0a7 To minimize shock, keep the patient from getting chilled or overheated. \uf0a7 Summon more advanced medical personnel for any critical burn. In addition, always check for inhalation injury if the person has a heat or chemical burn involving the face. With electrical burns, check carefully for other problems, such as difficulty breathing, cardiac problems and painful, swollen, deformed areas. Remember to take care with pediatric patients, especially infants, as they are prone to hypothermia. With electrical burns, check carefully for additional conditions, such as difficulty breathing, cardiac arrest and fractures."
    },
    {
        "KEY TERMS": "Chest tube: A tube surgically inserted into the chest to drain blood, fluid or air, and to allow the lungs to expand., Evisceration: A severe injury that causes the abdominal organs to protrude through the wound., Flail chest: A serious injury in which multiple rib fractures result in a loose section of ribs that does not move normally with the rest of the chest during breathing and often moves in the opposite direction., Hemopneumothorax: An accumulation of blood and air between the lungs and chest wall., Hemothorax: An accumulation of blood between the lungs and chest wall; caused by bleeding that may be from the chest wall, lung tissue or major blood vessels in the thorax., Hyperresonance: Abnormal sounds during percussion on the affected side of the chest., Hypotension: Abnormally low blood pressure., Impaled object: An object that remains embedded in an open wound; also referred to as an embedded object., Intercostal: Located between the ribs., Jugular venous distension (JVD): Neck veins that are swollen due to pressure from inside the vein., Parenchyma: Tissue that is involved in the functioning of a structure or organ as opposed to its supporting structures., Percussion: A technique of tapping on the surface of the body and listening to the resulting sounds, to learn about the condition of the area beneath., Peritoneum: The membrane that lines the abdominal cavity and covers most of the abdominal organs., Pleural space: The space between the lungs and chest wall., Pneumothorax: Collapse of a lung due to pressure on it caused by air in the chest cavity., Subconjunctival hemorrhage: Broken blood vessels in the eyes., Subcutaneous emphysema: A rare condition in which air gets into tissues under the skin that covers the chest wall or neck; may occur as a result of wounds to those areas., Sucking (open) chest wound: A chest wound in which an object, such as a knife or bullet, penetrates the chest wall and lung, allowing air to pass freely in and out of the chest cavity; breathing causes a sucking sound, hence the term., Tension pneumothorax: A life-threatening injury in which the lung is completely collapsed and air is trapped in the pleural space., Thoracic: Relating to the thorax, or chest cavity., Traumatic asphyxia: Severe lack of oxygen due to trauma, usually caused by a thoracic injury.",
        "INTRODUCTION": "Many injuries to the chest and abdomen involve only soft tissues. Often these injuries, like those that occur elsewhere on the body, are only minor cuts, scrapes, burns and bruises. Occasionally, a violent force or mechanism, known as trauma, results in more severe injuries. These include fractures and injuries to organs, which can cause severe bleeding or impair breathing. Occupants who are not wearing seat belts during motor-vehicle collisions often suffer fractures and lacerations. Falls, athletic injuries and many other forms of trauma may also cause such injuries. Injuries to the pelvis may be minor soft tissue injuries or serious injuries to bone and internal structures. Because the chest, abdomen and pelvis contain many organs important to life, injury to these areas can be fatal if left untreated. A force capable of causing severe injury in these areas may also cause injury to the spine. General care for these injuries includes: \uf0a7 Calling for more advanced medical personnel. \uf0a7 Limiting movement. \uf0a7 Monitoring breathing and other vital signs. \uf0a7 Controlling bleeding. \uf0a7 Minimizing shock.",
        "ANATOMY OF THE CHEST, ABDOMEN AND GENITALIA": "The chest cavity, also called the thoracic cavity, is the second-largest body cavity and contains the heart and lungs (Fig. 21-1). The ribs, sternum and upper portion of the spine (thoracic vertebrae) frame the wall of the thoracic cavity, also referred to as the thoracic cage. The diaphragm, a large muscular partition, separates the thoracic cavity from the abdominal cavity. Below the diaphragm is the abdominal cavity. The abdominal cavity contains the major organs of several of the body\u2019s systems: the digestive system, urinary system and endocrine system (Fig. 21-2). The abdominal cavity is lined with a thick membrane called the peritoneum, which supports the organs, including the stomach, gallbladder, urinary bladder, intestines, liver, spleen, pancreas and kidneys. It also contains important vascular structures such as the abdominal aorta and inferior vena cavae. Genitalia are part of the reproductive systems of women and men. The male genitalia include the testicles, a duct system and the penis. The female genitalia include the ovaries, fallopian tubes, uterus and vagina (Fig. 21-3).",
        "CHEST INJURIES": "Chest injuries are a leading cause of trauma deaths each year in the United States. Motor-vehicle collisions, direct blows and falls can all lead to chest injuries (Fig. 21-4, A\u2013C). Chest wounds can be either open or closed. Open chest wounds occur when an object, such as a knife or bullet, penetrates the chest wall. Open chest wounds also can be caused by fractured ribs that break through the skin. A chest wound is considered closed if the skin is not broken. Closed chest wounds are generally caused by a blunt object.",
        "CRITICAL FACTS": "Because the chest, abdomen and pelvis contain many organs important to life, injury to these areas can be fatal if left untreated. General care for these injuries includes calling for advanced medical personnel, limiting movement in the patient, monitoring breathing and other vital signs, controlling bleeding and taking steps to minimize shock.",
        "Types of Chest Injuries": "Certain types of chest injuries may be life threatening, and others merely cause discomfort. You will likely be able to recognize severe injuries. It is important to summon more advanced medical personnel in those situations.",
        "Blunt Trauma": "Blunt trauma is injury caused by the force of an object that impacts with, but does not penetrate, the body. Signs and symptoms include severe shortness of breath, chest pain and rapid, possibly irregular pulse. The possibility of blunt trauma should be considered in patients who sustain a blow to the abdomen or chest and show signs of respiratory distress. Often, associated injuries will occur with blunt trauma, including major trauma to the spleen, liver or large blood vessels. Therefore, it is not unusual for patients with these injuries to go into hypovolemic shock, a type of shock in which there is multiple organ failure due to major fluid loss\u2014usually blood.",
        "Traumatic Asphyxia": "Traumatic asphyxia , or severe lack of oxygen due to trauma, can result from chest injury. These injuries often are caused by a strong crushing mechanism or by situations in which patients have been pinned under a very heavy object. Signs and symptoms of traumatic asphyxia include: \uf0a7 Shock. \uf0a7 Distended neck veins. \uf0a7 Bluish discoloration of the head, tongue, lips, neck and shoulders (cyanosis). \uf0a7 Broken blood vessels in the eyes (subconjunctival hemorrhage ). \uf0a7 Black eyes. \uf0a7 Pinpoint-sized red dots (petechiae) on the head and neck. \uf0a7 Rounded, \u201cmoon-like\u201d facial appearance. \uf0a7 Bleeding from the nose or ear. \uf0a7 Coughing up or vomiting blood. \uf0a7 Loss of consciousness, seizures or blindness. Traumatic asphyxia is a very serious emergency that requires immediate intervention. If it is suspected, call for more advanced emergency medical services (EMS) personnel immediately. Assess the patient for associated chest and abdominal injuries. Elevate the patient\u2019s head to approximately 30\u00b0 to decrease pressure to the head. Establish and maintain adequate airway and breathing, and administer supplemental oxygen, based on local protocols.",
        "Fractured Ribs": "Rib fractures are usually caused by a forceful blow to the chest. Although painful, a simple rib fracture is rarely life threatening. The patient will usually attempt to ease the pain by leaning toward the side of the fracture and pressing a hand or arm over the injured area, thereby creating an anatomical splint. When ribs are fractured, suspect the possibility of internal injuries. The first priority with fractured ribs is adequate breathing. A patient with a fractured rib often has shallow breathing because normal or deep breathing is painful. Give the patient a rolled blanket or pillow to hold against the fractured ribs to immobilize the injured area. Use a sling and binder to hold the patient\u2019s arm against the injured side of the chest. Monitor breathing. Possible complications of fractured ribs include: \uf0a7 Collapse of a lung due to air in the chest cavity pressing on the lung (pneumothorax). \uf0a7 Accumulation of blood between the lungs and chest wall (hemothorax). \uf0a7 Air in the tissues under the skin (subcutaneous emphysema). \uf0a7 Bruising or piercing of the lung and injuries to the spleen or liver. \uf0a7 Lacerated blood vessels between the ribs.",
        "CRITICAL FACTS 1": "Certain types of chest injuries may be life threatening, and others merely cause discomfort. You will likely be able to recognize the difference. Blunt trauma is injury caused by the force of an object that impacts with, but does not penetrate, the body. Traumatic asphyxia, or severe lack of oxygen due to trauma, can result from chest injury. These injuries often are caused by a strong crushing mechanism or by situations in which patients have been pinned under a very heavy object.",
        "CRITICAL FACTS 2": "Rib fractures are usually caused by a forceful blow to the chest. A flail chest injury is a serious, life-threatening rib fracture. It results from a severe blow or crushing injury in which multiple ribs fracture in multiple places, causing loose sections of ribs that move abnormally in the chest.",
        "Flail Chest": "In situations involving severe blows or crushing injuries, multiple ribs can fracture in multiple places. These fractures can produce a loose section of ribs that does not move normally with the rest of the chest during breathing. Usually, the loose section will move in the opposite direction from the rest of the chest. This injury is called a flail chest, which is considered a serious rib fracture and can be life threatening. When a flail chest involves the breastbone, the breastbone is separated from the rest of the ribs. In flail chest, the lung tissues may be bruised, leading to inadequate oxygenation. There is also a risk of the ribs puncturing a lung. If you suspect a fractured rib or ribs, have the patient rest in a position that will make breathing easier. Binding the patient\u2019s arm to the chest on the injured side will help support the injured area and make breathing more comfortable. You can use an object such as a pillow or rolled blanket to help support and immobilize the injured area. Serious fractures often cause severe bleeding and trouble breathing, and shock is likely to develop. Administer supplemental oxygen based on local protocols, and continue to monitor the patient\u2019s vital signs.",
        "Pneumothorax": "Pneumothorax is the collapse of a lung due to air in the chest cavity pressing on the lung and preventing it from expanding. Pneumothorax can occur in two ways. In blunt chest trauma, it may result when a fractured rib penetrates the lung, causing air to leak. It can also occur when air enters the chest cavity because of a sucking (open) chest wound. Pneumothorax reduces lung pressure and leads to respiratory distress. Patients may report pain while breathing, and pain at the site of the rib fractures. Decreased breath sounds will be present upon examination, and many patients with traumatic pneumothorax also have some element of severe bleeding (hemorrhage), causing a hemopneumothorax. Patients with pneumothorax will require a chest tube in the hospital setting to fully re-expand the lung.",
        "Hemothorax": "Hemothorax is an accumulation of blood between the lungs and chest wall (pleural space) that creates pressure on the heart and lungs and prevents the lungs from expanding, resulting in the same symptoms as those which occur in pneumothorax. The bleeding that leads to hemothorax may be from the chest wall, the lung\u2019s functional tissue (parenchyma) or major blood vessels in the thorax. It may occur following blunt or penetrating injury to the chest, and often occurs together with pneumothorax. Again, patients will complain of pain and shortness of breath, and the condition may cause shock. During patient assessment, if trained to do so, you likely will note a decrease in breath sounds when listening and dullness when tapping (percussion) over the affected area. A massive hemothorax will also cause abnormal or unstable blood pressure.",
        "Tension Pneumothorax": "Tension pneumothorax is a serious, life-threatening injury in which there is complete collapse of the lung. Air enters the space around the lungs and remains trapped there. It is caused by the same traumas as those that produce a simple pneumothorax. Tension pneumothorax causes air to continue leaking from an underlying injury to the functional lung tissue (pulmonary parenchymal injury), which increases pressure within the affected side of the chest cavity. Patients experiencing a tension pneumothorax are typically in respiratory distress with diminished or absent breath sounds and abnormal sounds (hyperresonance) during percussion on the affected side of the chest. The trachea shifts away from the side of the injury (a very late sign of tension pneumothorax that may not be seen in the out-of-hospital setting) and the neck veins become swollen, which is known as jugular venous distension (JVD). The patient will show signs of unstable blood pressure, such as abnormally low blood pressure (hypotension), which can quickly develop into complete cardiovascular collapse. Extreme pressure in the chest cavity prevents blood from returning to the heart, and the blood is no longer pumped out. Death can occur quickly. Immediate care provided by advanced medical personnel for this life-threatening condition includes decompression of the affected lung by inserting a large-bore needle through the second or third intercostal space, along an imaginary line that passes through the midpoint of the clavicle (midclavicular line), or through the fourth or fifth intercostal space on the lateral chest wall. Typically, a chest tube is then inserted in the hospital setting.",
        "CRITICAL FACTS 3": "Tension pneumothorax is a serious, life-threatening injury in which there is complete collapse of the lung. Air enters the space around the lungs and remains trapped there.",
        "Signs and Symptoms of Chest Injuries": "You should know the signs and symptoms of serious chest injury. These may occur with both open and closed wounds. They include:\n\uf0a7 Shortness of breath and difficulty breathing.\n\uf0a7 Pain during breathing.\n\uf0a7 Pain at the site of the injury that increases with deep breathing or movement.\n\uf0a7 Obvious deformity, such as that caused by a fracture.\n\uf0a7 Flushed, pale, ashen or bluish discoloration of the skin.\n\uf0a7 Coughing up blood.\n\uf0a7 Distended (protruding) neck veins.\n\uf0a7 Drop in blood pressure.",
        "Chest Injuries - Providing Care": "Providing Care for a Sucking (Open) Chest Wound\nPuncture wounds to the chest range from minor to life threatening. A forceful puncture may penetrate the rib cage and allow air to enter the chest through the wound. This prevents the lungs from functioning normally.\nPuncture wounds cause varying degrees of internal or external bleeding. If the injury penetrates the rib cage, air can pass freely in and out of the chest cavity and the patient cannot breathe normally. With each breath the patient takes, you may hear a sucking sound coming from the wound. This is the primary sign of a penetrating chest injury, called a sucking (open) chest wound.\nWithout proper care, the patient\u2019s condition will worsen quickly. The affected lung or lungs will fail to function, and breathing will become more difficult. Your main concern is the breathing problem. To care for a sucking (open) chest wound, ensure that advanced medical personnel have been summoned. Control any bleeding with a sterile gauze dressing but do not let the wound become occluded by changing the dressings frequently.\nMost open chest wounds do not bleed heavily so you may be able to leave the wound uncovered and exposed to the air, based on local protocols. Because of the risk of creating a tension pneumothorax, most open chest wounds should be left uncovered and not be sealed unless advanced medical personnel are on scene to recognize and treat a tension pneumothorax should one develop. Some local protocols call for open chest wounds to be sealed with an occlusive dressing, one that does not allow air to pass through it. The most effective occlusive dressing is called a vented chest seal. Other occlusive dressings can be taped in place on all sides except for one side that should remain loose. Taping the dressing this way keeps air from entering the wound during inhalation but allows it to escape during exhalation. If none of these materials is available, a folded cloth or, as a last resort, your gloved hand, may be used. Administer supplemental oxygen, based on local protocols, and take steps to minimize shock. If no spinal injury is suspected, have the patient sit or lie in a comfortable position.",
        "Providing Care for Impaled Objects in the Chest": "An impaled object , or embedded object, is one that remains in an open wound. In the case of an impaled object in the chest, it is extremely important not to remove the object, unless it interferes with chest compressions. Instead, the object must be stabilized to keep it from moving. This can be accomplished by using a bulky dressing or gauze around the object. This will also assist in controlling bleeding.\nEmergency care for an impaled object includes the following steps:\n\uf0a7 Stabilize the object to prevent further damage.\n\uf0a7 Remove clothing to expose the wound.\n\uf0a7 Control bleeding by applying direct pressure to the edges of the wound (but avoid placing direct pressure on the object).\n\uf0a7 Use a sterile bulky dressing to help hold the object in place. Carefully pack the dressing around the object.\n\uf0a7 Secure the sterile bulky dressing in place with gauze, a cravat or tape.",
        "ABDOMINAL INJURIES": "The abdomen is the area immediately below the chest and above the pelvis. It is easily injured because it is not surrounded by bones, although it is protected at the back by the spine and ribs. The upper abdomen is only partially protected in front by the lower ribs. The muscles of the back and abdomen also help protect the internal organs, many of which are vital. Certain organs are easily injured or tend to bleed profusely when injured, such as the liver, spleen and stomach.\nThe liver is rich in blood. Located in the upper right quadrant of the abdomen, the lower ribs somewhat protect this organ. However, it is delicate and can be torn by blows from blunt objects or penetrated by a fractured rib. The resulting bleeding can be severe and quickly be fatal. The liver, when injured, can also leak bile into the abdomen, which can cause severe infection.\nThe spleen is located in the upper left quadrant of the abdomen, behind the stomach, and is protected somewhat by the lower left ribs. Like the liver, this organ is easily damaged. The spleen may rupture when a blunt object strikes the abdomen forcefully. Since the spleen stores blood, a spleen injury can cause a severe loss of blood in a short time and can be life threatening.\nThe stomach is one of the main digestive organs. The upper part of the stomach changes shape depending on its contents, the stage of digestion, and the size and strength of the stomach muscles. Many blood vessels and nerves line the stomach. It can bleed severely when injured, and food contents may empty into the abdomen and possibly cause infection.",
        "Acute Abdomen": "Abdominal pain is common and often not serious. However, acute and severe abdominal pain, referred to as acute abdomen, is usually a symptom of intra-abdominal disease such as appendicitis or peritonitis, but it may also be a symptom of abdominal trauma.",
        "Signs and Symptoms of an Abdominal Injury": "The signs and symptoms of serious abdominal injury include:\n\uf0a7 Severe abdominal pain.\n\uf0a7 Bruising. External bleeding.\nNausea and vomiting (sometimes vomit containing blood).\nPale or ashen, cool, moist skin.\nWeakness.\nThirst.\nPain, tenderness or a tight, swollen feeling in the abdomen.\nOrgans possibly protruding from the abdomen.",
        "CRITICAL FACTS 4": "With an impaled object injury to the chest, do not remove the object unless you need to do chest compressions. Stabilize it with bulky dressing or gauze to prevent further damage, and control bleeding by applying direct pressure to the edges of the wound.\nSigns and symptoms of serious chest injury are similar in both open and closed wounds. They include trouble breathing, including shortness of breath and pain when breathing (especially deep breathing); pain at the site of the injury; obvious deformity; pale or bluish skin; coughing up blood; protruding neck veins; and a drop in blood pressure.\nPuncture wounds to the chest range from minor to life threatening. A forceful puncture may penetrate the rib cage and allow air to enter the chest through the wound. This prevents the lungs from functioning normally.",
        "Assessment Techniques for Abdominal Injury": "Several steps must be taken when assessing a patient with a potential abdominal injury:\n\uf0a7 First, establish spinal motion restriction if a spinal injury is suspected.\n\uf0a7 Check the patient\u2019s position. Knees flexed toward the chest are a good indication the patient has suffered an abdominal injury.\n\uf0a7 Inspect the abdomen for contusions, lacerations, abrasions and punctures.\n\uf0a7 Look for signs of potential internal bleeding, including a distended abdomen as well as discoloration and bruising around the navel and sides.\n\uf0a7 Inspect the patient for internal organs protruding from an open abdominal wound (abdominal evisceration or disembowelment).\n\uf0a7 Palpate the four quadrants of the abdomen from the farthest point away from the pain, noting tenderness or masses.\n\uf0a7 If the patient has a decreased mental status, it is important to note grimacing or signs of pain as you palpate. Keep in mind that the patient may be contracting stomach muscles to avoid pain, or the contractions may be the result of muscle spasms.\n\uf0a7 Assess both the upper and lower extremities for injury and a pulse, as abdominal aortic injury may cause the pulses of the lower extremities to be weaker than the upper. If no foot pulses are found, check the pulses at the back of the knee or thigh. These should be equal to or stronger than the radial pulse, even in the case of shock.\n\uf0a7 Assess motor and sensory function.\n\uf0a7 Log roll the patient and inspect for signs of trauma on their back.\n\uf0a7 Assess baseline vital signs, especially for indications of blood loss and shock. Symptoms such as low blood pressure, rapid heartbeat or pale, cool, moist skin are all indications of shock.\n\uf0a7 Ensure that the airway is open and the patient is able to breathe adequately. If inspection of the airway shows signs of bloody vomitus, suctioning may be required. If the patient is not breathing adequately, begin positive pressure ventilation with supplemental oxygen based on local protocols.",
        "Providing Care for Abdominal Injury": "Like a chest injury, an injury to the abdomen is either open or closed. Even with a closed wound, the rupture of an organ can cause serious internal bleeding that can quickly result in shock. Injuries to the abdomen can be extremely painful. Serious reactions can occur if organs leak blood or other contents into the abdominal cavity. To care for a closed abdominal injury: \uf0a7 Carefully position the patient on their back. \uf0a7 Avoid applying direct pressure. \uf0a7 Bend the patient\u2019s knees slightly. Doing so allows the muscles of the abdomen to relax. Place rolled-up blankets or pillows under the patient\u2019s knees. If moving the patient\u2019s legs causes pain, or you suspect spinal injury, leave the legs straight. \uf0a7 Administer supplemental oxygen based on local protocols. \uf0a7 Take steps to minimize shock. \uf0a7 Summon more advanced medical personnel.",
        "Providing Care for Eviscerations": "A severe open injury may result in evisceration, a situation in which abdominal organs protrude through the wound. To care for an open wound in the abdomen, follow these steps: \uf0a7 Summon more advanced medical personnel. \uf0a7 Carefully position the patient on the back. \uf0a7 Avoid applying direct pressure.\uf0a7Avoid pushing the organs back in.\uf0a7Remove clothing from around the wound.\uf0a7Apply moist sterile or clean dressings loosely over the wound.\uf0a7Cover the dressings loosely with plastic wrap, if available.\uf0a7Cover the dressings lightly with a folded towel to maintain warmth.\uf0a7Keep the patient from getting chilled or overheated.\uf0a7Administer supplemental oxygen based on local protocols.",
        "CRITICAL FACTS 5": "Signs and symptoms of serious abdominal injury may include severe pain, tenderness or swollen feeling in the abdominal area; bruising; external bleeding; nausea and vomiting; pale or ashen, cool, moist skin; weakness; thirst; and protruding organs. To care for a closed abdominal injury, carefully position the patient on the back, avoid applying direct pressure, bend their knees slightly, administer supplemental oxygen based on local protocols, take steps to minimize shock and summon more advanced medical personnel.",
        "Providing Care for Impaled Objects in the Abdomen": "If the patient has been impaled by an object in the abdomen, it is important not to remove the object. Instead, dress the wound around the object to control the bleeding. Stabilize the object with bulky dressings to prevent movement.",
        "GENITAL INJURIES": "Assessing and treating a patient with a genital injury requires a calm and professional approach, as it can be embarrassing not only for the patient, but also for you. Using a sensitive approach to the patient\u2019s situation, such as clearing onlookers from the scene, supplying a drape for privacy and reassuring the patient, will help the process be less embarrassing. If possible, someone of the gender of the patient\u2019s choosing should treat them. Injuries to the penis usually occur as a result of an accident or assault. They can be either closed wounds, such as a bruise, or open wounds, such as an avulsion or laceration. Regardless, genital injuries are extremely painful. The female organs, like those of the male, can cause extreme pain when injured. However, these types of injuries are rare, as the female genitals are smaller and much more protected. Straddle injury and sexual assault are the most common situations in which the female genitals can be injured, as well as childbirth. Injuries can cause severe bleeding and pain due to the large amount of blood vessels in this area. Despite excessive bleeding, these injuries are rarely life threatening.",
        "Signs and Symptoms of Genital Injuries": "Signs and symptoms of genital injury are similar to those for an abdominal injury. They include: Severe pain. Bruising. External bleeding. Nausea. Vomiting (sometimes containing blood). Weakness. Thirst. Pain, tenderness or a tight feeling in the area. Protruding organs. Rigid abdominal muscles. Other signs of shock.",
        "CRITICAL FACTS 6": "Signs and symptoms of genital injury are the same as those for an abdominal injury. To care for injuries to the male genital region, remember never to remove an impaled object. Closed wounds to this area should be treated as any other closed wound injury. For open wounds, apply sterile dressing and direct pressure, either with your gloved hand or allow the patient to do it.",
        "CRITICAL FACTS 7": "To provide care for injury to the female genitals, control bleeding with pressure FACTS using compresses moistened with saline. Use a diaper-like dressing for the wound and stabilize any impaled objects with a bandage. Use cold packs over the dressing to reduce swelling and ease pain.",
        "Providing Care for Genital Injuries": "Care for a closed wound to the male genitals as you would for any closed wound. Wrap the penis in a soft, sterile dressing moistened with saline solution, and apply a cold pack to reduce pain and swelling. As with any injury, never  remove an impaled object. Stabilize the object and bandage it in place for transport. If the injury is an open wound, apply a sterile dressing and direct pressure with your gloved hand or the patient\u2019s hand, or use a protective barrier to avoid contact. In the case where the penis is partially or completely amputated, apply a sterile pressure dressing to help stop bleeding, which may be significant. Aggressive direct pressure may also be needed if bleeding is excessive. As with an avulsion, if the penis is found, follow the procedure for preserving and transporting body parts. If any parts are avulsed or completely amputated, wrap them in sterile gauze, moistened in sterile saline if available. Then place them in a plastic bag, labeled with the patient\u2019s name and the time and date they were placed in the bag. Keep the bag cool by placing it in a larger bag or container of ice and water slurry, not on ice alone and not on dry ice. Transfer the bag to the EMS personnel transporting the patient to the hospital. It is also possible for injuries to affect the scrotum and testicles. A blow to this area can rupture the scrotum and can cause pooling of blood, which is extremely painful. A ruptured testicle requires surgery. Apply a cold pack to the area to reduce swelling and pain, and if the scrotal skin has become avulsed, try to find it. Wrap the skin in sterile dressing and transport with the patient. The scrotum should be dressed with gauze sterilized and moistened with saline. Apply pressure to control bleeding. To provide care for injury to the female genitals, control bleeding with pressure using compresses moistened with saline. Use a diaper-like dressing for the wound and stabilize any impaled objects with a bandage. Use cold packs over the dressing to reduce swelling and ease pain. Never  place anything in the vagina, including dressing. Treat the patient for shock as required. Remember your training regarding a crime scene if you suspect a patient has been a victim of sexual assault. Take care to provide the patient with privacy by clearing the area of onlookers and draping a sheet or blanket over the patient. Do not touch the genitals; discreetly ask if the patient has suffered any other injuries, such as to the head. If bleeding is life threatening, this will take priority over maintaining the integrity of the crime scene. Do not allow the patient to bathe or douche, and discourage the patient from washing their hair or cleaning under their fingernails. Unless injuries are life threatening, do not clean or touch any wounds. Handle the patient\u2019s clothing as little as possible, placing them in paper bags separately from any other items. If there is blood on the items, do not use plastic bags and be sure to follow local protocols.",
        "PUTTING IT ALL TOGETHER": "Injuries to the chest, abdomen or genitalia can be serious. They can damage soft tissues, bones and internal organs. Although many injuries are immediately obvious, some may be detected only as the patient\u2019s condition worsens over time. Watch for signs and symptoms of serious injuries that require immediate medical attention. Care for any life-threatening condition and then give any additional care needed for specific injuries. Always  call for more advanced medical personnel as soon as possible. Have the patient remain as still as possible. For open wounds to the chest, abdomen or genitalia, control bleeding. If you suspect a fracture, immobilize the injured part. Use occlusive dressings for open abdominal wounds when these materials are available. Your actions can make the difference in the patient\u2019s chances of survival. You Are the Emergency Medical Responder  As you begin your assessment, you notice that the young woman has multiple gunshot wounds to her chest and abdomen. How should you care for this patient?CRITICAL FACTSTo provide care for injury to the female genitals, control bleeding with pressure using compresses moistened with saline. Use a diaper-like dressing for the wound and stabilize any impaled objects with a bandage. Use cold packs over the dressing to reduce swelling and ease pain."
    },
    {
        "KEY TERMS": "Adult respiratory distress syndrome (ARDS): A lung condition in which trauma to the lungs leads to inflammation, accumulation of fluid in the alveolar air sacs, low blood oxygen and respiratory distress., Arteries: Large blood vessels that carry oxygen-rich blood from the heart to all parts of the body, except for the pulmonary arteries, which carry oxygen-poor blood from the heart to the lungs., Bandage: Material used to wrap or cover a part of the body; commonly used to hold a dressing or splint in place., Bandage compress: A thick gauze dressing attached to a gauze bandage., Bleeding: The loss of blood from arteries, veins or capillaries., Blood volume: The total amount of blood circulating within the body., Capillaries: Tiny blood vessels linking arteries and veins that transfer oxygen and other nutrients from the blood to all body cells and remove waste products., Clotting: The process by which blood thickens at a wound site to seal an opening in a blood vessel and stop bleeding., Contusion: An injury to the soft tissues that results in blood vessel damage (usually to capillaries) and leakage of blood into the surrounding tissues; caused when blood vessels are damaged or broken as the result of a blow to the skin, resulting in swelling and a reddish-purple discoloration on the skin; commonly referred to as a bruise., Direct pressure: Pressure applied on a wound to control bleeding., Dressing: A pad placed directly over a wound to absorb blood and other body fluids and to prevent infection., Elastic bandage: A bandage designed to keep continuous pressure on a body part; also called an elastic wrap., External bleeding: Bleeding on the outside of the body; often, visible bleeding., Golden Hour: A term that refers to the critical first hour after a patient sustains a life-threatening traumatic injury; the highest risk of dying from shock or bleeding occurs during this time; providing early interventions and advanced medical care to the patient as soon as possible within the hour can result in the best chance of patient survival., Head-on collision: A collision in which a vehicle hits an object, such as a tree or other vehicle, straight on., Hemorrhage: The loss of a large amount of blood in a short time or when there is continuous bleeding., Hemostatic dressing: A dressing treated with an agent or chemical that assists with the formation of blood clots; used with direct pressure to help control severe, life-threatening bleeding., Internal bleeding: Bleeding inside the body., Occlusive dressing: A special type of dressing that does not allow air or fluid to pass through., Perfusion: The circulation of blood through the body or through a particular body part for the purpose of exchanging oxygen and nutrients with carbon dioxide and other wastes., Pressure bandage: A bandage applied snugly to create pressure on a wound, to aid in controlling bleeding., Roller bandage: A bandage made of gauze or gauze-like material that is wrapped around a body part, over a dressing, using overlapping turns until the dressing is covered., Rollover: A collision in which the vehicle rolls over., Rotational impact: A collision in which the impact occurs off center and causes the vehicle to rotate until it either loses speed or strikes another object., Side-impact collision: A collision in which the impact is at the side of the vehicle; also known as a broadside, t-bone or lateral collision., Tourniquet: A tight, wide band placed around an arm or a leg to constrict blood vessels in order to stop blood flow to a wound., Trauma dressing: A dressing used to cover very large wounds and multiple wounds in one body area; also called a universal dressing., Trauma system: A regional or community-based system that provides definitive care for injured (trauma) patients; provides patients with a seamless transition from prehospital care to acute and post-hospital care, leading to improved patient outcomes. A comprehensive trauma system also participates in community outreach activities, including injury prevention programs., Triangular bandage: A triangle-shaped bandage that can be rolled or folded to hold a dressing or splint in place; can also be used as a sling to support an injured shoulder, arm or hand., Veins: Blood vessels that carry oxygen-poor blood from all parts of the body to the heart, except for the pulmonary veins, which carry oxygen-rich blood to the heart from the lungs.",
        "INTRODUCTION": "Bleeding is the loss of blood from arteries, veins or capillaries. Bleeding is either internal or external. External bleeding is usually obvious because it is typically visible. Internal bleeding is often difficult to recognize. Uncontrolled bleeding, whether internal or external, is a life-threatening emergency. A large amount of bleeding occurring in a short time is called a hemorrhage. If left untreated, severe bleeding can result in shock and, eventually, death. Check for and control severe, life-threatening bleeding during the primary assessment before you check for breathing and a pulse. You may not identify internal bleeding until you perform a more detailed check during the physical exam and history.",
        "INCIDENCE/SIGNIFICANCE OF TRAUMA": "The Golden Hour refers to the critical first hour after a patient sustains a life-threatening traumatic injury. The highest risk of dying from shock or bleeding occurs during this time. Providing early interventions and advanced medical care to the patient as soon as possible within the hour can result in the best chance of patient survival. Trauma is a physical injury, wound or shock caused by an agent, force or mechanism. The trauma patient requires rapid assessment and care of the conditions found. This is often done by a multidisciplinary team, supported by the appropriate healthcare providers, to minimize or eliminate the risk of death or permanent disability. A trauma system must determine the necessary level of care for the injury.",
        "TRAUMA SYSTEM": "A trauma system is a regional or community-based system that provides definitive care for injured (trauma) patients. These systems consist of many different components that provide patients with a seamless transition from prehospital care to acute and post-hospital care, leading to improved patient outcomes. A comprehensive trauma system also participates in community outreach activities, including injury prevention programs. There are four primary levels of facilities for trauma care: \uf0a7 Level I trauma center: This facility must have the capability to deal with all levels and types of patient injury on a 24-hour basis. These facilities are leading medical care facilities, often university-based teaching hospitals, and must have an adequate depth of resources and personnel to deal with all levels of patient care. These facilities also conduct research and community outreach. \uf0a7 Level II trauma center: This facility is expected to be able to provide definitive care to patients, despite the type of injury the patient may have suffered. Its care capabilities are generally the same as a Level I trauma center, but they may not conduct research. \uf0a7 Level III trauma center: These facilities are often found in smaller communities that do not have immediate access to larger Level I or Level II trauma centers. They can provide prompt assessment, resuscitation and emergency operations, and arrange for transport to a Level I or II facility as required. \uf0a7 Level IV trauma center: These facilities are often rural clinics in remote areas and can generally only offer initial patient care until arrangement for transportation can be made. Treatment protocols for resuscitation, transfer protocols, data reporting and participation in system performance improvement are essential at a Level IV trauma center. In selecting the appropriate level of trauma center, transport considerations must also be taken into account. State and regional guidelines dictate the maximum transport time depending on the acuity of the patient; for example, whether the patient has an uncontrolled hemorrhage or a compromised airway. Similar to adult patients, pediatric trauma patients are often transported to the nearest pediatric trauma center, even if it is farther away than other hospitals, based on local trauma triage guidelines and local point-of-entry plans.",
        "MULTI-SYSTEM TRAUMA": "Patients who are subjected to significant forces are at an increased risk for injuries to multiple organs within the body at the same time. A multi-system trauma is one involving more than one body system. For example, a patient who was in a major collision may have broken bones (skeletal system), but may also be experiencing difficulty breathing (respiratory system). Multi-system trauma patients are also at a greater risk of developing shock (see Chapter 18). Suspect multi-system trauma in any patient subjected to significant external forces.",
        "PERFUSION": "Perfusion is the circulatory system\u2019s method of delivering oxygen and nutrients while eliminating carbon dioxide and other wastes. The entire body requires perfusion, but different parts of the body require different amounts. Some organs are especially sensitive to changes in the efficiency of perfusion. For example, a major organ such as the heart, when denied constant perfusion, cannot function properly. The brain can only last about 4 to 6 minutes without constant perfusion before damage could begin to occur. Kidneys can last up to 45 minutes without perfusion. The skeletal system can withstand a lack of perfusion for as long as 2 hours before damage becomes permanent.",
        "CRITICAL FACTS 1": "Bleeding is the loss of blood from arteries, veins or capillaries. Bleeding is either internal or external. External bleeding is usually obvious because it is typically visible. Internal bleeding is often difficult to recognize. A trauma system is a regional or community-based system that provides definitive care for injured (trauma) patients. These systems consist of many different components that provide patients with a seamless transition from prehospital care to acute and post-hospital care, leading to improved patient outcomes.",
        "BLEEDING - General Considerations": "To reduce the risk of disease transmission when controlling bleeding, always follow standard precautions, including: \uf0a7 Avoiding contact with the patient\u2019s blood, directly or indirectly, by using barriers such as disposable latex-free gloves and protective eyewear. \uf0a7 Avoiding eating, drinking and touching your mouth, nose or eyes while providing care or before washing your hands. \uf0a7 Always washing your hands thoroughly before (if practical) and after providing care, even if you wore gloves or used other barriers. \uf0a7 Changing gloves before you care for a different patient, and cleaning equipment (e.g., handles) and surfaces (e.g., zippers and door knobs) after providing care. The severity of blood loss can be estimated based on the signs and symptoms with which the patient presents, as well as your general impression of the amount of blood loss. It is important to control bleeding. Uncontrolled bleeding, or significant blood loss, will lead to shock and possibly death. Do not wait for shock to develop before providing care to someone who is injured or suddenly ill.",
        "Types of Bleeding": "Bleeding is the loss of blood from arteries, veins or capillaries and can result in either internal or external bleeding. The most severe of these is arterial bleeding, followed by venous bleeding. Hemorrhaging occurs when a large amount of blood is lost in a short period of time or when there is continuous bleeding.",
        "Arterial Bleeding": "Arterial bleeding is typically the most urgent type of bleeding. Arterial blood is oxygenated and pumped from the heart to supply the body with nutrients. External arterial bleeding can be caused by both blunt and penetrating trauma. Arterial bleeding can also occur when organs and blood vessels are damaged. Arterial blood: \uf0a7 Is bright red. \uf0a7 Spurts from the wound as it is being pushed by the heart\u2019s pumping action. \uf0a7 Will not clot or stop easily because of the pressure. \uf0a7 Decreases in pressure as the patient\u2019s blood pressure drops, due to decreased blood volume.",
        "Venous Bleeding": "Venous bleeding is usually the result of an outside force causing trauma or an internal force breaking through a vein, such as a broken bone or organ damage. The blood is returning to the heart so it does not have as much pressure to move it forward. Bleeding from a vein can be severe. Venous blood: \uf0a7 Is darker red than arterial blood. \uf0a7 Flows steadily, but the flow can still be quick and severe. \uf0a7 May be easier to stop because it does not have the same pressure as arterial bleeding.",
        "Capillary Bleeding": "Capillary bleeding is not usually a concern in healthy people. It is usually slow because the vessels are small and the blood is under low pressure. Capillary blood: \uf0a7 Is darker red than arterial blood. \uf0a7 Oozes from the capillaries. \uf0a7 Usually clots spontaneously or with direct pressure.",
        "CRITICAL FACTS": "The most severe bleeding is typically arterial bleeding, followed by venous bleeding. Hemorrhaging occurs when a large amount of blood is lost in a short period of time or when there is continuous bleeding.",
        "Dressings": "Dressings are pads placed directly on the wound to absorb blood and other fluids and to prevent infection. To minimize the chance of infection, dressings should be sterile. Most dressings are porous, allowing air to circulate to the wound to help promote healing. Standard dressings include varying sizes of cotton gauze (sterile and nonsterile), commonly ranging from 2- to 4-inch squares (i.e., 2-inch x 2-inch pads). Much larger dressings, called universal dressings or trauma dressings, are used to cover very large wounds and multiple wounds in one body area. Some dressings have nonstick surfaces to prevent the dressing from sticking to the wound. A special type of dressing, called an occlusive dressing, does not allow air or fluids to pass through. Plastic wrap and petroleum jelly-soaked gauze are examples of this type of dressing. Occlusive dressings are used for open abdominal wounds. For more information on the use of an occlusive dressing, refer to Chapter 21.",
        "Application of Dressings": "For most dressings, place pressure directly on the wound with a sterile gauze pad. Place your fingers or hand over the gauze pad and apply firm, direct pressure. If you do not have gauze available, apply pressure with your own gloved hand or have the injured person apply pressure with the hand.",
        "Bandages": "A bandage is any material used to wrap or cover any part of the body. Bandages are used to hold dressings in place, to apply pressure to control bleeding, to help protect a wound from dirt and infection, and to provide support to an injured limb or body part. Many different types of bandages are available commercially. A bandage applied snugly to create pressure on a wound or injury is called a pressure bandage. A common type of bandage is a commercial adhesive compress. Available in assorted sizes, an adhesive compress consists of a small pad of nonstick gauze (the dressing) on a strip of adhesive tape (the bandage) applied directly to small injuries. Also available is the bandage compress, a thick gauze dressing attached to a gauze bandage. This bandage can be tied in place. Because it is designed to help control severe bleeding, the bandage compress usually comes in a sterile package. A roller bandage is usually made of gauze or gauze-like material. Some gauze bandages are made of a self-adhering material that easily conforms to different body parts. Roller bandages are available in assorted widths from \u00bd to 12 inches and lengths from 5 to 10 yards. A roller bandage is generally wrapped around the body part, over a dressing, using overlapping turns until the dressing is completely covered. It can be tied or taped in place. A folded strip of roller bandage may also be used as a dressing or compress. In Chapter 22, you will learn to use roller bandages to hold splints in place. A special type of roller bandage is an elastic bandage, sometimes called an elastic wrap. Elastic bandages are designed to keep continuous pressure on a body part. When properly applied, they can effectively control swelling or support an injured limb. Elastic bandages are available in assorted widths from 2 to 6 inches. They are very effective in managing injuries to muscles, bones and joints. Elastic bandages are frequently used in athletic environments and should be applied only by those who are trained and proficient in their use. Another commonly used bandage is the triangular bandage. When it is folded, it can hold a dressing or splint in place on most parts of the body. Used as a sling, the triangular bandage can support an injured shoulder, arm or hand.",
        "Application of Bandages": "A pressure bandage will hold gauze pads in place while maintaining direct pressure. To apply a roller bandage, follow these general guidelines:\n\uf0a7 Secure the end of the bandage in place. Wrap the bandage around the body part until the dressing is completely covered and the bandage extends several inches beyond the dressing. Tie or tape the bandage in place.\n\uf0a7 Do not cover fingers or toes, if possible. By keeping these parts uncovered, you will be able to tell if the bandage is too tight. If fingers or toes become cold, numb or begin to turn pale, ashen or blue, the bandage is too tight and should be loosened slightly.\n\uf0a7 If blood soaks through the bandage, do not remove the original dressing or bandage, but remove excess blood-soaked bandages. Then apply an additional dressing and another bandage and reapply firm direct pressure. Elastic bandages can easily restrict blood flow if not applied properly. Restricted blood flow is not only painful but also can cause tissue damage if not corrected.",
        "External Bleeding": "External bleeding is usually easy to control. Follow standard precautions when providing care. Wash your hands before (if possible) and after providing care, and wear disposable latex-free gloves. You may use alcohol-based hand sanitizers if there is no visible matter present and soap and water are not available.",
        "External Bleeding - Providing Care": "When treating a bleeding patient, apply a sterile gauze dressing or trauma pad over the wound and then apply direct pressure to the wound with your gloved hand. If necessary, use your gloved hand to begin applying direct pressure to the wound while someone else obtains the necessary material(s). If conscious and able, the patient may use their hand to apply pressure while you obtain the necessary equipment or perform other, more urgent duties. For severe bleeding, apply strong, direct pressure to the wound to counter the pressure from the beating heart. Use fingertip pressure (using the flat part of fingers) first to control bleeding. If the wound is large and fingertip pressure does not work, use hand pressure with gauze dressings to stop the bleeding. If you are controlling bleeding from an open fracture, do not apply direct pressure over the bones but instead pack sterile gauze around the area to control bleeding and prevent infection. If the dressing becomes saturated with blood while you are applying pressure, do not remove the original dressing or bandage. Instead, leave the original and replace other dressings and bandages with new dressings and reapply direct pressure. Then cover the dressings with a bandage to hold them in place. Adding multiple dressings and bandages can reduce the overall effectiveness of the dressings by spreading the pressure out over a wider area. Keep the patient warm and position them flat on their back. Care for other conditions, including shock. Part of your care for severe bleeding is to always assess and care for shock, since the risk of (hypovolemic) shock is high with significant blood loss. Do not give food or drink if shock is suspected.",
        "Nosebleeds": "Nosebleeds are usually self-contained and can most often be stopped easily. They can be caused by trauma or develop from a medical reason, such as dryness or high blood pressure. In your assessment of the patient, you can expect to find pain or tenderness in the area and bleeding from the nose. The patient could also vomit swallowed blood. For an unconscious patient, a nosebleed can potentially block the airway. To care for a nosebleed:\n\uf0a7 Ensure the conscious patient is sitting in an upright position.\n\uf0a7 Tilt the patient\u2019s head and upper body forward slightly, if possible, to prevent swallowing or choking on the blood.\n\uf0a7 Pinch the patient\u2019s nostrils together firmly for about 5 to 10 minutes to slow down the blood flow.\n\uf0a7 Tell the patient not to sniffle or blow their nose.\n\uf0a7 Do not pack the patient\u2019s nose to stop the bleeding. As with bleeding from external wounds, monitor the patient for signs of shock if the bleeding does not stop. If you suspect a fractured skull, do not try to stop a nosebleed as this might increase pressure on the brain. Instead, cover the nostrils loosely with sterile gauze and call for more advanced medical personnel.",
        "To tie a bandage": "(A) Begin by placing the end of the bandage on the dressing at a 45-degree angle. (B) Wrap the bandage one full turn, and then fold the angled end of the bandage up, creating a \u201cdog-ear.\u201d (C) Continue wrapping the bandage, overlaying the \u201cdog ear\u201d to anchor it and moving upward. (D) Once the dressing is covered, roll out the remaining length of bandage. (E) While holding the bandage, use the index finger of the other hand to split the bandage in half, moving it down and underneath the limb. (F) Bring the two ends of the bandage up and tie them in a bow or knot.",
        "Other Methods to Control Severe, Life-Threatening Bleeding": "For a wound that is bleeding severely, if direct pressure fails to control the bleeding or is not possible, application of a manufactured (commercial) tourniquet or a hemostatic dressing by a properly trained responder can be considered. Manufactured tourniquets are preferred over makeshift or homemade devices. For wounds not on an extremity or when a tourniquet is not available or effective, a hemostatic dressing with firm direct pressure may be considered, following the manufacturer\u2019s instructions and local protocols.",
        "Tourniquets": "A tourniquet is a device placed around an arm or leg to constrict blood vessels and stop blood flow to a wound. In some life-threatening circumstances, you may need to use a tourniquet to control bleeding as the first step instead of maintaining direct pressure over several minutes. Examples of situations where it may be necessary to use a tourniquet include: \uf0a7 Severe, life-threatening bleeding that cannot be controlled using direct pressure. \uf0a7 A physical location that makes it impossible to apply direct pressure to control the bleeding (e.g., the injured patient or their limb is trapped in a confined space). \uf0a7 Multiple patients with life-threatening injuries who need care and there are limited resources available. \uf0a7 A scene that is or becomes unsafe. Tourniquets can be extremely painful. If you must apply a tourniquet, make sure the patient understands the reason for the tourniquet, and warn them that it may be painful. If you find yourself in a situation where you need to apply a tourniquet, follow the manufacturer\u2019s instructions for applying it. Although tourniquets may have slightly different designs, all are applied in generally the same way. First, place the tourniquet around the wounded extremity about 2 inches above the wound, avoiding the joint if possible. Secure the tourniquet tightly in place according to the manufacturer\u2019s instructions. Twist the rod (windlass) to tighten the tourniquet until the bleeding stops, then secure the rod in place. Note and record the time that you applied the tourniquet, and be sure to give the transporting personnel this information when they arrive. Once the tourniquet is applied, it should not be removed until the patient reaches a healthcare facility. Skill Sheet 19-2 describes step-by-step how to apply a commercially manufactured tourniquet. If it is necessary to use a tourniquet and a commercially manufactured tourniquet is not available, make a tourniquet using a strip of soft material that is 2 to 4 inches wide (such as a triangular bandage that has been folded into a tie) and a short, sturdy stick or other rigid object. Tie the stick or other rigid object into the material and twist it to tighten the makeshift tourniquet.",
        "Hemostatic Dressings": "A hemostatic dressing is a dressing treated with an agent or chemical that speeds up clotting. As is the case with tourniquets, hemostatic dressings are used when severe, life-threatening bleeding exists and standard procedures (direct pressure) for bleeding control fail or are not practical. Typically, hemostatic dressings are used on parts of the body where a tourniquet cannot be applied, such as the neck, torso and junctional areas such as the abdomen and groin. Hemostatic dressings may also be used on extremities when a tourniquet is not available or is not effective. Hemostatic dressings must be applied at the site of the bleeding and be packed deep inside the wound along with direct pressure. Follow the manufacturer\u2019s instructions for proper application of the hemostatic dressing according to local protocols. To be effective, hemostatic dressings require continuous direct pressure at the source of the bleeding until the bleeding is controlled (Fig. 19-13). Any time a hemostatic dressing is applied, the patient needs to be evaluated by a healthcare provider.",
        "Splints": "In an open wound to an extremity where the bone or joint is also injured, the bone ends or fragments can be displaced and cause damage to soft tissues and blood vessels, causing further bleeding. Using a splint to immobilize the extremity can help prevent this problem. If the wound is over an open fracture (on the bones), do not apply direct pressure but instead pack sterile gauze around the area to control bleeding and prevent infection.",
        "INTERNAL BLEEDING Causes": "Internal bleeding is the escape of blood from arteries, veins or capillaries into spaces in the body. Internal bleeding can be caused by a variety of injuries or conditions, including blunt force trauma. For example, the impact of the chest or head against the steering wheel during a motor-vehicle collision can cause internal bleeding. It can also be caused by a fracture, which may cause bones to pierce internal organs. Because this type of damage may not be visible, it may lead to extensive concealed bleeding. It may also cause unexplained shock. Internal bleeding can also occur along with external bleeding. For example, if a patient is bleeding from a knife wound, the blade may have penetrated an organ, which then begins bleeding inside the body. The patient may experience injuries to extremities, causing pain, swelling or deformity. This may lead to serious internal blood loss from long bone fractures. Internal bleeding is not always easy to recognize unless the patient is losing blood from the ears, mouth, vagina, rectum or possibly from the nose. As with external bleeding, arterial bleeding is typically the most severe. The strength of the heartbeat will cause the blood to flow from the blood vessels into the interior of the body quickly and with great force.",
        "Signs and Symptoms of Internal Bleeding": "Some signs and symptoms of internal bleeding include: \uf0a7 Discoloration of the skin around the area (bruising) on the neck, chest, abdomen or side. \uf0a7 Nausea, vomiting or coughing up blood. \uf0a7 Discolored, painful, tender, swollen or firm tissue (e.g., the abdomen). \uf0a7 Tenderness and guarding (protecting the area). Signs and symptoms of shock may be present, including: Anxiety or restlessness., Rapid, weak pulse., Rapid breathing., Skin that feels cool or moist or that looks pale, ashen or bluish., Excessive thirst., Declining level of consciousness (LOC)., Drop in blood pressure.",
        "Internal Bleeding - Providing Care": "If a patient is bleeding internally:\n\uf0a7 Call for more advanced medical personnel if serious internal bleeding is suspected.\n\uf0a7 Ensure the patient remains as still as possible, to reduce the heart\u2019s blood output.\n\uf0a7 Care for shock.\nWhen internal bleeding is from the capillary blood vessels, the result is bruising around the wound area and is not serious. To reduce discomfort for the patient, you can apply a cold pack.",
        "PUTTING IT ALL TOGETHER": "One of the most important things you can do in any emergency is to recognize and control severe bleeding. External bleeding is easily recognized and should be cared for immediately. Check and care for severe, life-threatening bleeding as you form your general impression and conduct the primary assessment. Severe external bleeding is life threatening. Although internal bleeding is less obvious, it also can be life threatening. Recognize when a serious injury has occurred and suspect internal bleeding. You may not identify internal bleeding until you perform the physical exam and patient history. When you identify or suspect severe bleeding, quickly transport or arrange for transport of the patient to a hospital. Continue to provide care until more advanced medical personnel take over.\nDo not wait for shock to develop before providing care to someone who is injured or suddenly ill, especially if there is blood loss or if the normal function of the heart is interrupted. Care for life-threatening conditions, such as severe external bleeding, before caring for lesser injuries. Remember that managing shock effectively begins with recognizing a situation in which shock may develop, and providing appropriate care. Summon more advanced medical personnel immediately if you notice signs and symptoms of shock. Shock can often be reversed by advanced medical care, but only if the patient is reached in time.",
        "CRITICAL FACTS 2": "Some signs and symptoms of internal bleeding include bruising on the neck, chest, abdomen or side; nausea, vomiting or coughing up blood; patient guarding the area; rapid pulse or breathing; skin that is cool or moist or looks pale, ashen or bluish; excessive thirst; declining LOC and drop in blood pressure.\nIf a patient is bleeding internally, call for more advanced medical personnel, keep the patient still and care for shock.",
        "Using Direct Pressure to Control External Bleeding": "NOTE: Always follow standard precautions when providing care. STEP 1: Cover the wound with a sterile gauze pad and apply direct pressure until the bleeding stops. If blood soaks through the dressing, leave the original dressing in place, but remove any excess dressings or bandages and apply a new one on top. Then apply additional direct pressure (press harder than you did before, if possible). It may take several minutes for the bleeding to stop. STEP 2: When the bleeding stops, check for circulation (feeling, warmth and color) beyond the injury. STEP 3: Apply a roller bandage. Wrap the bandage around the wound several times to hold the gauze pad(s) in place. Tie or tape the bandage to secure it. Check for circulation (feeling, warmth and color) beyond the injury. If there is a change in feeling, warmth or color (indicating that the bandage is too tight), gently loosen it. STEP 4: Remove your disposable latex-free gloves and wash your hands. NOTE: If the bleeding does not stop with the application of direct pressure, call for more advanced medical personnel if you have not already, and give care for shock if necessary.",
        "Applying a Tourniquet": "NOTE: Always follow the manufacturer\u2019s instructions and local protocols when applying a tourniquet. Always follow standard precautions when providing care. After conducting a scene size-up, checking the patient and having someone else call for more advanced medical personnel and then determining that standard first aid care for bleeding (direct pressure) is not effective or appropriate for controlling the severe, life-threatening bleeding: STEP 1: Place the tourniquet around the limb, approximately 2 inches above the wound. Avoid placing the tourniquet over a joint. STEP 2: Route the tag end of the strap through the buckle of the tourniquet, if necessary. STEP 3: Pull the strap tightly and secure it in place. STEP 4: Tighten the tourniquet by twisting the rod (windlass) until the flow of bleeding stops and then secure the rod in place. Do not cover the tourniquet with clothing. STEP 5: Note and record the time that you applied the tourniquet, and give this information to the transporting personnel when they arrive to take over care.",
        "Vehicle Collisions": "Motor-vehicle collisions are some of the most frequent scenes to which an emergency medical responder (EMR) may be called. Collisions are categorized as head-on impact, rear impact, side impact, rotational impact and rollover. Each collision category shows a predictable pattern of injury, which is influenced by the type of restraint the occupant was using at the time of the collision.",
        "Head-on collision": "A head-on collision is one in which a vehicle hits an object, such as a tree or a stopped vehicle, straight on. When the car makes impact in a head-on collision, the bodies of the occupants will continue to move until they strike an object such as a secured seat belt, an air bag, the steering wheel or the windshield. Additionally, the organs within the body also continue to move forward until they strike an internal structure such as the sternum or skull. Injuries common to head-on collisions include face, head, neck, chest and abdominal injuries. This is also true for rear-impact collisions.",
        "Side-impact collisions": "In side-impact collisions, also known as broadside, lateral or t-bone collisions, the person on the impact side of the crash sustains more injuries than do occupants on the opposite side. Due to the impact sustained during a side-impact collision, the body moves one way and the head the other. This makes head and neck injuries more common. Chest and pelvic injuries are also possible in this situation.",
        "Rotational impact": "Rotational impact occurs off center, when the car strikes an object and rotates around it until the car either loses speed or strikes another object. Injuries similar to head-on and side-impact collisions can be expected in these cases.",
        "Rollovers": "Rollovers see the occupants of the car changing positions as the car does. In these cases, predicting injury is impossible, as every object in the car becomes potentially lethal. If occupants are not wearing seat belts, it is more likely that they may be thrown from the car, dramatically increasing the likelihood of death. Common injuries in rollovers include soft tissue injuries, multiple broken bones and crushing injuries.",
        "Blunt Trauma and Restraints": "When someone is struck by or falls against a blunt object\u2014one with no sharp edges or points\u2014the resulting injuries are often closed wounds. This means that, although the soft tissues of skin, muscle, nerves and blood vessels may be damaged, the skin is not broken and there is no visible bleeding. The patient may look unharmed, but there may be serious, even fatal, injury to the internal organs and significant internal bleeding. Proper use of restraints in a vehicle will help to lessen the likelihood of injury for the occupants. However, injuries can still be sustained. Restraints vary based on the type of vehicle, and some can be more effective than others in preventing injury. Lap belts: Prevent occupants from being thrown from a car; do not prevent head, neck and chest injuries; can cause internal injuries if not worn properly; can cause injury to the diaphragm. Lap and shoulder belts: Prevent occupants from striking the steering wheel and dashboard; upon severe impact can cause damage to the clavicle; do not prevent head and neck injury. Air bags: Are located in the steering wheel, dashboard and/or side curtains; must have high impact to deploy; are fully effective only when occupants are wearing seat belts; can cause burns, contusions (bruises) and other, more serious injuries; protect the occupant only from the first collision in a multi-collision crash. Head rests: When properly adjusted, limit the effects of head, neck and spinal injuries.",
        "Pediatric Considerations in Vehicle Collisions": "Because an air bag could seriously injure or even kill a child, or even an adult of short stature, these individuals are safest in the rear seat. A child or an infant in a rear-facing seat is close to the dashboard and could easily be struck by the air bag with sufficient force to cause serious harm or even death. Older children who have outgrown child seats are also at risk from a deploying air bag, if not properly restrained. Infants should always be transported in car seats. Infant car seats facing backward help prevent head and neck injuries. The greatest danger is to the infant\u2019s neck. Seats vary, based on the age and size of the occupant.",
        "Motorcycle Crashes": "In motorcycle crashes, there are four potential scenarios: head-on, angular, ejection and laying the bike down. The purpose of laying the bike down is to minimize impact in the case of an impending crash. The rider may turn the motorcycle sideways and drag a leg along the ground to lose speed in order to get off the bike. This can result in severe burns and abrasions, but lessens the likelihood of internal injuries. Head-on impacts will usually result in the driver impacting the handlebars at the same speed the bike is traveling. Multiple injuries can result.",
        "Angular Impact": "Angular impact can result in severe amputations, as the rider strikes an object at an angle.",
        "Ejection from Bike": "Ejection from the bike causes the rider to fly over the handlebars, which can result in severe head, spinal and face injury, especially if the rider is not wearing a helmet.",
        "ATV Crashes": "All-terrain vehicle (ATV) crashes commonly result in head, neck and extremity injuries similar to those seen in motorcycle collisions. These vehicles are prone to crashes and rollovers.",
        "Falls": "A significant number of trauma-related injuries each year are caused by falls, particularly among older adults. The severity of the injury depends on: the distance of the fall; any interruptions during the fall; which body parts impact first; the surface on which the patient lands; the patient\u2019s physical condition before the fall took place. Feet-first falls cause energy to travel up the skeleton as the patient lands. Spine, hip socket, femur, heel and ankle are the most common sites for injury from these falls. Headfirst falls begin with the arms and extend to the shoulders on impact. Spine and head injuries are common. Chest, lower back and pelvis injuries often occur. Falls on the side of the head (as in skiing incidents) often do not show signs and symptoms until 1 to 2 hours after the injury. Encourage patients to seek care.",
        "Penetrating Injuries": "When an object is pushed through the surface and soft tissue of the body, a penetrating injury occurs. Low-velocity injuries occur with hand-powered weapons such as knives or arrows. The severity depends on location, weapon length, and attacker\u2019s strength. Medium-high velocity injuries are caused by guns. Tissue damage can be extensive even if the surface wound appears minor.",
        "Blast Injuries": "Explosions produce unique, multiple injuries and are categorized into four types. Primary blast injury is caused by blast overpressure affecting tissues like lungs, ears and GI tract. Secondary blast injury occurs from flying debris and often causes penetrating trauma. Tertiary blast injury is due to the body being thrown by the blast. Miscellaneous (quaternary) blast injuries include burns, crush injuries, and inhalation of toxins. Wheezing in blast injury may stem from pulmonary contusion, toxic gas inhalation, pulmonary edema, or ARDS. Determine material involved, patient\u2019s proximity to blast, and signs of radiation/chemicals."
    },
    {
        "Key Terms": "Air splint: A hollow, inflatable splint for immobilizing a part of the body., Anatomic splint: A splint formed by supporting an injured part of the body with an uninjured, neighboring body part; for example, splinting one finger against another; also called a self-splint., Angulation: An angular deformity in a fractured bone., Binder: A cloth wrapped around a patient to securely hold the arm against the patient\u2019s chest to add stability; also called a swathe., Bone: A dense, hard tissue that forms the skeleton., Cardiac muscle: A specialized type of muscle found in the heart., Circumferential splint: A type of splint that surrounds or encircles an injured body part., Closed fracture: A type of fracture in which the skin over the broken bone is intact., Cravat: A folded triangular bandage used to hold splints in place., Crepitus: A grating or popping sound under the skin that can be due to a number of causes, including two pieces of bone rubbing against each other., Direct force: A force that causes injury at the point of impact., Dislocation: The displacement of a bone from its normal position at a joint., Extremity: A limb of the body; upper extremity is the arm; lower extremity is the leg., Fracture: A break or disruption in bone tissue., Immobilize: To use a splint or other method to keep an injured body part from moving., Indirect force: A force that transmits energy through the body, causing injury at a distance from the point of impact., Joint: A structure where two or more bones are joined., Ligament: A fibrous band that holds bones together at a joint., Muscle: A tissue that contracts and relaxes to create movement., Open fracture: A type of fracture in which there is an open wound in the skin over the fracture., Rigid splint: A splint made of rigid material such as wood, aluminum or plastic., Self-splint: A splint formed by supporting one part of the body with another; also called an anatomic splint., Smooth muscles: Muscles responsible for contraction of hollow organs such as blood vessels or the gastrointestinal tract., Soft splint: A splint made of soft material such as towels, pillows, slings, swathes and cravats., Splint: A device used to immobilize body parts., Sprain: The partial or complete tearing or stretching of ligaments and other soft tissue structures at a joint., Strain: The excessive stretching and tearing of muscles or tendons; a pulled or torn muscle., Swathe: A cloth wrapped around a patient to securely hold the arm against the patient\u2019s chest, to add stability; also called a binder., Tendon: A fibrous band that attaches muscle to bone., Traction splint: A splint with a mechanical device that applies traction to realign the bones., Twisting force: A force that causes injury when one part of the body remains still while the rest of the body is twisted or turns away from it., Vacuum splint: A splint that can be molded to the shape of the injured area by extracting air from the splint., Voluntary muscles: Muscles that attach to bones; also called skeletal muscles.",
        "INTRODUCTION": "Although musculoskeletal injuries are almost always painful, they are rarely life threatening. However, when not recognized and taken care of properly, they can have serious consequences and even result in permanent disability or death. Broken bones, dislocated joints, strained muscles and similar injuries are common, and most people will experience one or more of these during their lifetime. Injuries to muscles, bones and joints range from simple, minor problems such as a sprained finger, to serious situations such as a fractured pelvis. In this chapter, you will learn how to recognize and care for muscle, bone and joint injuries. Developing a better understanding of the structure and function of the body\u2019s framework will help you assess musculoskeletal injuries and give appropriate care.",
        "CRITICAL FACTS": "The musculoskeletal system is a combination of two body systems\u2014the muscular and skeletal systems. It consists of the bones, muscles, and tendons and ligaments. There are three types of muscles: the voluntary muscles, smooth muscles of the walls of organs and cardiac muscles of the heart. Muscles, bones and joints are injured when force is applied to them. The three basic mechanisms of injury (MOIs) are direct force, indirect force and twisting force.",
        "MUSCULOSKELETAL SYSTEM": "The musculoskeletal system is a combination of two body systems\u2014the muscular and skeletal systems. It consists of the bones, muscles, tendons and ligaments. The skeletal system creates a structural framework for the body and is composed of approximately 206 bones of varying shapes and sizes. Six sections comprise the skeleton: the skull, spine, thorax, pelvis, upper extremities and lower extremities. There are three types of muscles: the voluntary muscles, smooth muscles of the walls of organs, and cardiac muscles of the heart. Voluntary muscles, also called skeletal muscles, are the major muscles that make up the body and enable movement. Ligaments and tendons join structures of the musculoskeletal system together. Ligaments hold the bones at a joint together and tendons connect muscle to bone. have a normal range of movement\u2014an area in which they can move freely without too much stress or strain. When joints are forced beyond this range, ligaments can stretch and tear. Muscles and tendons can also become stretched or torn when placed under a lot of stress or worked too hard.",
        "INJURIES TO MUSCLES, BONES AND JOINTS - Causes of Injury": "Muscles, bones and joints are injured when force is applied to them. Knowing the specific mechanism, or cause, of injury can give you important clues about which parts of the body may be injured, what other hidden injuries may exist along with the more obvious ones and how serious the injuries may be. There are three basic mechanisms of injury (MOIs): \uf0a7 Direct force causes injury at the point of impact. For example, the patient may have been hit by a loose pitch during a baseball game, fracturing the bone in the ankle. \uf0a7 Indirect force transmits energy through the body and causes injury at some distance from the original point of impact. For example, the patient might have a fall from a galloping horse, and stretch out the arms while landing so that the hands hit the ground first. The collarbone is broken when the force is transmitted up the arm to the shoulder. \uf0a7 Twisting force, or rotating force, causes injury when one part of the body remains still while the rest of the body is twisted or turned away from it. For example, a patient may be skiing and fall to the side, causing a leg to twist while still in a ski boot that is pointing downhill.",
        "Types of Injuries": "The four basic types of injuries to muscles, bones and joints are fractures, dislocations, strains and sprains.",
        "Fractures": "A fracture is a break or damage to a bone. Fractures can involve bones that are broken all the way through, chipped or cracked. A fall, a blow or sometimes even a twisting movement can cause a fracture. Some fractures are obvious, but others may not be easy to detect without an X-ray. While most isolated fractures are not considered critical or life threatening, if the femur or pelvis is fractured, the patient is at serious risk of excessive blood loss, shock and death. These two bones contain many blood vessels, and any injury tends to cause heavy bleeding. Fracture to the spine can also result in damage to the spinal cord. There are two kinds of fractures: \uf0a7 Closed fractures : The skin over the broken bone is intact. \uf0a7 Open fractures : There is an open wound in the skin over the fracture. In some cases, the broken bone actually protrudes from the skin or is visible through the wound. While closed fractures are more common, open fractures are more dangerous because they carry a risk of infection and severe bleeding. In general, fractures are life threatening only if they involve breaks in large bones such as the femur, sever an artery or affect breathing. Since you cannot always tell if a person has a fracture, you should consider the MOI. A fall from a height or a motor-vehicle crash could signal a possible fracture. When in doubt, suspect a fracture and provide care accordingly.",
        "Dislocations": "Dislocations are usually more obvious than fractures. A dislocation is the displacement of a bone at a joint away from its normal position (Fig. 22-5). The bones in the human body are linked together at joints. When the bones that normally meet at a particular joint have been displaced or separated from each other, and the ligaments or tendons have been stretched, displaced or torn, this is called a dislocation. Some joints, such as the shoulder and fingers, dislocate more easily because they are relatively exposed and not as well protected by ligaments. Other joints, such as the elbow, are less likely to become dislocated, but are just as serious as any joint dislocation. In general, dislocation requires a severe force. However, if a joint has become dislocated once and the ligaments holding the bones in place were damaged, subsequent dislocations are then more likely to occur. In some cases, dislocation can become chronic so that relatively minor movements can cause joint instability. A force strong enough to cause an initial dislocation can also cause a fractured bone, bleeding and damaged nerves, so it is important to check for those injuries as well. A dislocation can be extremely painful.",
        "Sprains": "A sprain is the partial or complete tearing or stretching of ligaments and other tissues at a joint (Fig. 22-6, A). If the bones that meet at a joint are forced beyond their usual range of movement, the ligaments can be stretched or torn even though the bones are not actually dislocated. The greater the number of ligaments torn, the more severe is the injury. Severe sprains, caused by a great deal of force being applied, can also involve fractured or dislocated bones. Milder sprains are caused when the only injury is stretched ligaments. Patients generally find that the pain of these mild sprains is quickly resolved and they return to their normal activities. However, this often leads to re-injury of the joint that was sprained. Proper care should always be given once ligaments have been stretched or torn, even if the injury is mild. Otherwise, the joint may become less stable and the partially healed, less stable joint will be much more susceptible to re-injury. The joints most easily injured are at the ankle, knee, wrist and fingers.",
        "Strains": "A strain is the excessive stretching and tearing of muscles or tendons, sometimes called a pulled muscle or a tear (Fig. 22-6, B). Tendons are stronger than muscles and more resistant to injury, so damage more often happen in muscles or at the attachment between the muscle and tendon. Strains can result from overexertion, such as lifting something too heavy, or from working a muscle for too long. They can also result from sudden or uncoordinated movements. Strains most often involve the muscles in the neck, back, thigh or calf. Like sprains, strains are often neglected and this may lead to re-injury. The muscles need time and rest to repair the damage. Repeated strains of the neck and back are common causes of workers being absent from work.",
        "Assessing Signs and Symptoms of Injuries to Muscles, Bones and Joints": "Injuries to the musculoskeletal system are identified during the physical examination. Because these injuries often appear to be similar, it may be difficult for you to determine exactly what type of injury has occurred. As you complete the physical examination, think about how the body normally looks and feels. Check for deformity; compare the injured side to the uninjured side. Ask how the injury happened. The cause of the trauma may alert you to the possibility that the muscles, bones and joints have been injured. As the patient or bystanders explain how the injury occurred, listen for clues, such as a fall from a height or a serious motor-vehicle crash. Also ask the patient if any areas are painful. Then carefully examine the entire body, starting with the head. Keep in mind as you assess the patient that if there was sufficient force present to fracture a bone or dislocate a joint, that force may also cause bleeding, internal injuries and shock. Fractures can cause severe pain and there may be so much focus on this that the patient will not mention other problems such as abdominal pain, which may actually indicate more serious injuries. Some common signs and symptoms associated with musculoskeletal injuries include: \uf0a7 A snapping sound. If a bone has fractured, the patient may report hearing or feeling the bone snap or break. \uf0a7 Deformity or angulation. If you suspect injury in one arm or leg but not the other, compare the two arms or two legs to see if the injured limb is bent at an abnormal angle, or has changed in shape compared to the uninjured one. Other fractured bones may show indentations, and a dislocated joint often shows an indentation where the bones would normally meet.\uf0a7 Pain and tenderness. The pain of a fractured bone or dislocated joint is often severe. \uf0a7 Crepitus . There may be a grating sound or feeling when attempting to move the fractured bone, caused by the two pieces of bone rubbing against each other. \uf0a7 Swelling. Swelling may be present and may obscure some indentations. \uf0a7 Restricted movement. The patient may be unable to move the affected area, due to pain or because of a dislocated joint. \uf0a7 Visible break. In an open fracture, the broken ends of the bones may be visible. \uf0a7 Bruising or discoloration. Internal bleeding may cause bruising as blood pools under the skin. \uf0a7 Loss of circulation or sensation. There may be a loss of circulation or sensation in an extremity (the shoulders to the fingers; the hips to the toes). It is often impossible to determine whether a patient has experienced a fracture, dislocation, sprain or strain at the initial examination. X-rays and other tests by a healthcare provider will determine the precise nature of the injuries. Fortunately, it is not necessary to know whether the swelling of an ankle, for example, is caused by a fracture or a sprain to provide appropriate care.",
        "Providing Care for Injuries to Muscles, Bones and Joints": "A gentle, reassuring approach is important in caring for patients with muscle, bone and joint injuries. The patient is likely to be experiencing severe pain and may be frightened. Avoid moving the injured parts of the patient\u2019s body as much as possible, as this is likely to increase the pain and may cause further injury. Keep the injured area stable in the position found until more advanced medical personnel take over. For any muscle, bone or joint injury, follow these general guidelines when providing care: \uf0a7 Follow standard precautions. \uf0a7 Control bleeding if present. \uf0a7 Ensure that the patient is breathing effectively, and administer supplemental oxygen based on local protocols. \uf0a7 If a spinal injury is suspected, maintain spinal motion restriction and keep the patient flat. \uf0a7 Avoid any movements or changes in position that cause pain. The patient will usually find the most comfortable position. Keep the injured area immobile in that position. \uf0a7 Remove any jewelry or restrictive clothing in the affected area so that swelling does not cause more pain or injury. \uf0a7 Clean and bandage any open wounds before splinting. \uf0a7 Follow the steps on Skill Sheets 22-1 to 22-4 to immobilize the injured joint or bones with splints only if you must transport the patient to definitive medical care and you can do so without causing more pain. \uf0a7 Check for circulation and sensation to the limb. Feel for the patient\u2019s distal pulse, skin temperature, and ability to move and detect touch in the injured parts, before and after splinting. Call for more advanced medical personnel if: \uf0a7 You suspect a fracture to an area proximal to the wrist or ankle. \uf0a7 The injury involves severe bleeding. \uf0a7 The injury impairs breathing. \uf0a7 The injury involves the head, neck or spine. \uf0a7 You see or suspect multiple injuries. The general care for all musculoskeletal injuries is similar: rest, immobilize, cold and elevate, or \u201cRICE.\u201d",
        "CRITICAL FACTS 2": "Signs and symptoms of musculoskeletal injuries include a snapping sound, deformity/angulation, pain and tenderness, crepitus, swelling, restricted movement, bruising, and loss of circulation or sensation. Call for more advanced medical personnel if you suspect a fracture to an area proximal to the wrist or ankle; if the injury involves severe bleeding or impairs breathing, involves the head, neck or spine; or if you see or suspect multiple injuries.",
        "Rest": "Rest Avoid any movements or activities that cause pain. Help the patient find the most comfortable position. If you suspect head, neck or spinal injuries, leave the patient lying flat.",
        "Immobilize": "Stabilize the injured area in the position it was found. In most cases, it will not be necessary to apply a splint. For example, the ground can provide support to an injured leg, ankle or foot, or the patient may cradle an injured elbow or arm in a position of comfort.",
        "Cold": "Apply a cold pack for periods of 20 minutes. If 20 minutes cannot be tolerated, apply a cold pack for periods of 10 minutes. If continued cold is needed, remove the pack for 20 minutes, and then replace it. Cold helps reduce swelling and eases pain and discomfort. Commercial cold packs can be stored in a kit until ready to use, or you can make a cold pack by placing ice (crushed or cubed) with water in a plastic bag and wrapping it with a towel or cloth. Place a thin layer of gauze or cloth between the source of cold and the skin to prevent injury to the skin. Do not apply a cold pack directly over an open fracture, because doing so would require you to put pressure on the open fracture site and could cause discomfort to the patient. Instead, place cold packs around the site. Do not apply heat, as there is no evidence that applying heat helps.",
        "Elevate": "Elevating the injured area above the level of the heart helps slow the flow of blood, helping to reduce swelling. Elevation is particularly effective in controlling swelling in extremity injuries. However, never attempt to elevate a seriously injured area of a limb unless it has been adequately immobilized. Also, only elevate it if it does not cause additional pain.",
        "SPLINTING": "When an injury to bones, muscles or joints is suspected, immobilizing the affected body part is an important step in treatment. Preventing the bones, joints and ligaments from moving helps to reduce the risk of further injury, and minimizes the risks of some possible complications such as: \uf0a7 Broken bone ends injuring blood vessels, nerves or muscles as they move. This can cause loss of sensation in the affected area or increase the bleeding. \uf0a7 Broken bone ends breaking through the skin. \uf0a7 Blood vessels being compressed by broken or dislocated bones, thus reducing blood flow. \uf0a7 Paralysis caused by damage to the spine. The purposes of immobilizing an injury are to: \uf0a7 Lessen pain. \uf0a7 Prevent further damage to soft tissues. \uf0a7 Reduce the risk of severe bleeding. \uf0a7 Reduce the possibility of loss of circulation to the injured part. \uf0a7 Prevent closed extremity injuries from becoming open extremity injuries. A tool or device used to immobilize an injury is called a splint . There are many commercially manufactured types of splints, but if necessary one can be improvised from items available at the scene.",
        "CRITICAL FACTS 3": "Immobilizing an injury is important. It lessens pain, prevents further damage to soft tissues, reduces the risk of severe bleeding, reduces the possibility of loss of circulation to the injured part and prevents closed injuries from becoming open injuries.",
        "Rules for Splinting": "No matter where the splint will be applied, or what the injury is, there are some general rules for splinting:\n\uf0a7 Splinting should only be performed if you have to move or transport the patient to receive medical care and you can do so without causing more pain.\n\uf0a7 Assess the patient\u2019s distal pulse, skin temperature, ability to move and ability to feel the body part that is on the other side of the injury from the heart. For example, if the elbow has been injured, check pulse, skin temperature, mobility and sensation at the wrist. If a leg bone is injured, check at the ankle. Continue to assess these three signs every 15 minutes after the splint has been applied. This will let you know if the splint, or swelling under the splint, has impaired circulation to the affected area.\uf0a7 If a fracture is suspected, immobilize the joints above and below the injury. For example, if a bone in the lower leg is broken, you would immobilize the ankle and the knee. If a joint injury is suspected, immobilize the bone above and below the injury.\n\uf0a7 Cut off or remove any clothing around the injury site. If the patient is wearing a watch or jewelry near the injury, these should also be removed. Swelling may occur beyond the actual injury site. If an elbow is injured, for example, any bracelets, watches or rings on the wrist and hand should be removed.\n\uf0a7 Cover any bleeding or open wounds, including open fractures, with sterile dressings, and carefully bandage with minimal pressure.\n\uf0a7 Do not try to push protruding bones back below the skin. Do not attempt to straighten any angulated fracture; always splint the limb in the position found.\nDo not allow the patient to bear weight on an injured lower extremity.\nPad the splints you are using so that they will be more comfortable and conform to the shape of the injured body part.\nSecure the splint in place with folded triangular bandages, roller bandages or other wide strips of cloth.\nElevate the splinted part, if possible.",
        "Types of Splints": "Whether commercially made or improvised, there are six general types of splints: soft, rigid, traction, circumferential, vacuum, and anatomic or self-splint.",
        "Soft Splints": "Soft splints include folded blankets, towels, pillows, slings, swathes (also called binders) and cravats. Many improvised splints are made from soft materials such as bed pillows or blankets, and they can be effective if secured properly. A swathe is a cloth wrapped around a patient to securely hold the arm against the patient\u2019s chest, to add stability. Cravats are folded triangular bandages used to hold splints in place. A sling is a type of soft splint made from a triangular bandage. It can provide stability when the shoulder, elbow or upper arm has been injured. The sling will support the weight of the arm. To immobilize the injury, you should then apply a binder \u2014wrapping the cloth around the patient and the arm to hold the arm securely against the side of the patient\u2019s chest. With both the sling and binder in place, the arm will not be able to move, the weight of the arm will be supported and the patient\u2019s pain should be significantly reduced.",
        "Rigid Splints": "A rigid splint is one that is made of a rigid material such as wood, aluminum, plastic, cardboard or composite materials. Some are specially shaped to be used for a particular body part, such as an arm or a finger. Some are designed to be pliable so they can be shaped to the body part. They may come with padding or require padding to be added at the time of use. If commercial splinting materials are not available, improvised rigid splints can be created from cardboard boxes, rolled-up magazines, an athlete\u2019s shin guards or other items available at the scene. Look for an item that is light but rigid, and strong enough to resist breaking. It should be long enough to prevent movement on either side of the injury, and wide enough that it will cover the entire injured area. You should also be able to pad it effectively to protect the skin and any wounds.",
        "Traction Splints": "A traction splint contains a mechanical device that is attached to the body part above and below the injury and provides a steady counter-pull. This is not the same as applying manual traction to realign the bones, and these splints are not intended to reposition fractured bones. Instead, they reduce pain and blood loss by immobilizing bones that might otherwise move in the direction opposite to the splint\u2019s pull. Each brand or type of traction splint will have instructions about correct use.",
        "Circumferential Splints": "A circumferential splint surrounds or encircles the injured body part. One example is a commercial air splint, which begins as a soft, pliable splint that can be positioned around the injured area. It is then filled with air and becomes rigid and applies pressure to the injured area. Air splints have the potential to interfere with circulation, making it difficult to check the patient\u2019s pulse or temperature. They can, however, be helpful in reducing bleeding. Air splints should only be used under medical direction.",
        "Vacuum Splints": "A vacuum splint starts out soft and pliable so that it can be shaped to fit the area that has been injured. Once it is in place, the air can be sucked out, creating a vacuum inside and making the splint rigid and immobilizing.",
        "Anatomic or Self-Splints": "In many cases, the patient\u2019s own body can act as a splint. This is called an anatomic splint or self-splint. For example, if the right leg is broken, the left leg can be used as a splint. The legs are fastened together using cravats or roller bandages. Any gaps between the legs are filled with padding.",
        "Splinting Upper Extremities": "The upper extremities are the arms and hands. The bones in the upper extremities are the collarbone, scapula, humerus, radius and ulna, as well as the bones in the hand, wrist and fingers. The upper extremities are the most commonly injured parts of the body. Since people who are falling or about to crash instinctively try to protect themselves by throwing out their arms and hands, these areas receive the force of the impact. Often, the result is a fracture, sprain or dislocation.",
        "Splinting the Collarbone": "When the collarbone is broken, the patient\u2019s shoulder may look lower than the uninjured side. You may see obvious deformity in the collarbone. It is best splinted with a sling, to reduce the pull from the arm\u2019s weight, and a binder to immobilize the arm against the chest.",
        "Splinting the Shoulder": "A dislocated shoulder will appear deformed and a hollow may be visible in the upper arm below the shoulder. This injury is extremely painful. There is a risk that nerves and arteries near the shoulder can be damaged by movement, so be cautious as you apply any splints. A sling and binder should be used, with some padding between the arm and the chest to maintain a reasonably comfortable position.",
        "Splinting the Upper Arm": "The humerus is a strong bone, so if it is broken (most often near the shoulder or partway towards the elbow), check for other injuries, as considerable force probably was involved. This injury can be splinted with a padded rigid splint on the outside of the arm. If the elbow can be comfortably bent, you can then use a sling and binder. If the elbow cannot be bent without causing more pain, or if the rigid splint you are using is longer than the upper arm, keep the arm straight at the patient\u2019s side and wrap the bandages or binders around the arm and chest.",
        "Splinting the Elbow": "Do not attempt to straighten or bend the elbow or change its position. If the elbow is bent, even if it is deformed, splint with a sling and binder. You may use a flat pillow or towel wrapped around the injured area and then secured to the chest. If the elbow is straight, use rigid splints along the length of both sides of the arm, from fingertips to underarm.",
        "Splinting the Forearm and Wrist": "A rigid splint extending from the elbow to the fingertips should be applied first. Then a sling and binder can be applied to support the arm against the chest (Fig. 22-18). If there is no open wound, a circumferential air splint, extending from elbow to past the fingertips, can be applied instead of the rigid splinting.",
        "Splinting the Hands and Fingers": "If a single finger has a broken bone, you may be able to create a self-splint or anatomic splint by taping the injured finger to the one beside it. A tongue depressor or similar-sized piece of cardboard can also work as a rigid splint, taped to the finger. When several fingers have broken bones or the back of the hand is involved in the injury, you will need to splint the entire hand. To immobilize the hand, place a small ball, or a rolled-up bandage or face cloth, inside the palm of the person\u2019s hand, with the fingers curled naturally around it. Then wrap the entire hand, and splint the lower arm and wrist with a rigid splint or arm board. A sling can be added to help support the arm.",
        "Splinting the Pelvis": "Injuries to the pelvis are potentially life threatening because of the risk of heavy bleeding in this area. Assess the patient for shock and internal blood loss. To immobilize a pelvic fracture, a pelvic binder can be used, following the manufacturer\u2019s instructions and if you are trained to apply one. If a pelvic binder is not available, one can be improvised using a sheet that is repeatedly folded lengthwise to create a thick, 8-inch-wide strip. Slide this strip under the small of the patient\u2019s back and pull it through until equal lengths appear on each side of the patient\u2019s body. Using the extended ends of the fabric, slide the strip of fabric down so that it is behind the injured pelvis, and cross the ends in front of the pelvis. Twist the ends together so that the fabric is tightly secured around the pelvis. Tuck the leftover fabric ends under the patient or tie them in a knot. Alternatively, the patient can be lowered onto an ambulance stretcher with the pelvic sheet and/or a long backboard in place, using a scoop stretcher, based on local protocols. Use a blanket or pillow for padding between the patient\u2019s legs, and add padding on both sides of the patient\u2019s hips. Minimize movement of the pelvis and legs.",
        "Splinting the Hip": "The hip is the joint where the thigh bone, or femur, fits into the pelvis. Like the pelvis, the femur has significant blood vessels, and any injury in this area can cause dangerous bleeding, which can be difficult to detect. Look for swelling in the thigh area. Assess and treat for bleeding and shock before beginning to splint. To immobilize the hip you will need to splint the patient\u2019s entire body on a long backboard.",
        "Splinting the Femur": "As mentioned previously, injuries to the femur can be very serious because of the risk of bleeding, which may be internal and not noticed. A broken femur causes a great deal of pain and significant swelling; the deformity of the thigh is usually quite noticeable, and the muscle often contracts (shortens) with this type of break. The leg may also be turned inward or outward. Use a traction splint if one is available and you have the training to apply this type of splint correctly. If a traction splint cannot be applied, you can use two long rigid splints instead, with padding to fill any gaps between the splint and the patient\u2019s body. One splint or board must start at the patient\u2019s groin area and extend past the bottom of the patient\u2019s foot, on the inside of the affected leg. The other should go from the patient\u2019s armpit to below the bottom of the patient\u2019s foot. Wrap the boards tightly, using cravats at the chest, hips, knees and ankles to immobilize the body.",
        "Splinting the Knee": "Knees may be injured in either a bent or straight position. Do not attempt to change the position of the knee. If it is straight, use two padded rigid splints, one on the outside and one on the inside of the leg. The inside splint should start at the groin and extend past the bottom of the foot. The outside splint should start at the hip and also extend past the foot. Use cravats to keep the splints in place. If the knee is bent, use a pillow or folded blanket under the knee to maintain the bent position. Then use short, padded rigid splints running along either side of the knee to immobilize the upper and lower leg in relationship to the knee.",
        "Splinting the Tibia and Fibula (Lower Leg Bones)": "The tibia (shinbone) and fibula are the two bones that extend from the knee to the ankle. The tibia is covered by only a thin layer of skin, so open fractures of this bone are common. The fibula is not a weight-bearing bone and fractures of this bone may not be as easily detected. Injuries to either bone are splinted in the same way, using a circumferential air splint, extending from above the knee to below the foot. Or you can use two padded rigid splints, one on the inside running from the groin to below the foot, and the other on the outside running from the hip to below the foot.",
        "Splinting the Ankle and Foot": "Injuries to the foot or ankle are often caused by heavy objects falling on the foot, or when a falling person lands on the feet. Twisting forces during a fall or while running can also cause an ankle injury. Whether the injury is a break or a sprain, both should be splinted in the same way, by immobilizing the entire foot and ankle. A circumferential air splint is a good choice, but a pillow or thick blanket wrapped around the foot and ankle and secured in place will also work.",
        "PUTTING IT ALL TOGETHER": "Injuries to bones, muscles and joints are generally caused by significant force, so careful assessment should be done to identify or rule out other injuries. Injuries can include fractures to bones; dislocations of joints; and strains and sprains involving muscles, ligaments and tendons. It is not always easy to identify the type of injury present.\nInjuries to the pelvis or femur are potentially critical because of the major blood vessels running through these parts of the body. Assess the patient for bleeding and shock.Assess for severe, life-threatening bleeding and take steps to control bleeding if necessary. Ensure that the patient is breathing effectively and provide supplemental oxygen based on local protocols. If a spinal injury is suspected, maintain spinal motion restriction and keep the patient flat. Avoid any movements or changes in position that cause pain. Help the patient find the most comfortable position. Remove any jewelry or restrictive clothing in the affected area.\nClean and bandage any open wounds before splinting. Follow guidelines to immobilize the injured joint or bones with splints. Check the patient\u2019s pulse and ability to move and detect touch in the injured parts before and after splinting. Apply a cold pack to reduce swelling and ease pain and discomfort. If there is no spinal injury and the limb has been securely immobilized, elevate it so that it is above the level of the patient\u2019s heart.\nIn most cases, splinting the injured area will help prevent further damage, reduce bleeding and reduce pain. A variety of commercial splints are available for this purpose; many splints can be improvised if commercial products are not available. After splinting, check every 15 minutes to see that the patient\u2019s pulse, ability to move, skin temperature, color and ability to detect touch in the part of the body past the injured area are still stable.\nYou Are the Emergency Medical Responder  \nAfter approaching the driver, you find out that she slammed her knee into the dashboard and cannot put weight on the right leg without significant pain. The ambulance has not yet arrived on scene. How should you respond? What actions should you take?",
        "Applying a Rigid Splint": "Follow standard precautions and obtain consent. Support the injured body part above and below the site of the injury. Check for circulation and sensation beyond the injured area. Place an appropriately sized rigid splint (e.g., padded board) under the injured body part. Place padding, such as a roller gauze, under the palm of the hand to keep it in a normal position. Tie several folded triangular bandages above and below the injured body part. Recheck for circulation and sensation beyond the injured area. If a rigid splint is used on an injured forearm, immobilize the wrist and elbow. Bind the arm to the chest using folded triangular bandages or apply a sling. If splinting an injured joint, immobilize the bones on either side of the joint.",
        "Applying a Sling and Binder": "Follow standard precautions and obtain consent. Support the injured body part above and below the site of the injury. Check for circulation and sensation beyond the injured area. Place a triangular bandage under the injured arm and over the uninjured shoulder to form a sling. Tie the ends of the sling at the side of the neck. Bind the injured body part to the chest with a folded triangular bandage. Recheck for circulation and sensation beyond the injured area.",
        "Applying an Anatomic Splint": "Follow standard precautions and obtain consent. Support the injured part above and below the site of the injury. Check for circulation, feeling, warmth and color beyond the injury. Place several folded triangular bandages above and below the injured body part. Align body parts. Place the uninjured body part next to the injured body part. Place padding between the body parts and fill any voids. Tie the bandages securely around both legs. Recheck for circulation: feeling, warmth and color. If you are not able to check warmth and color because a sock or shoe is in place, check for feeling.",
        "Applying a Soft Splint": "Follow standard precautions and obtain consent. Support the injured body part above and below the site of the injury. Check for circulation and sensation beyond the injured area. Place several folded triangular bandages above and below the injured body part. Gently wrap a soft object (e.g., a folded blanket or pillow) around the injured body part. Tie triangular bandages securely with knots. Recheck for circulation and sensation beyond the injured area. If you are not able to fully check circulation because a sock or shoe is in place, check for sensation.",
        "Agricultural and Industrial Emergencies": "Because of the heavy equipment involved, some of the most serious injuries occur on agricultural and industrial sites. You can expect to see crush injuries, avulsions, amputations, and other major open and closed soft tissue and musculoskeletal injuries.",
        "Scene Size-Up and Safety": "As always, size up the scene of an agricultural or industrial emergency before entering. Never enter a scene if there is any risk to your safety. Look out for toxic chemicals, fires or fire hazards, unstable or running machinery, and unsecured livestock. If necessary, call specialized personnel, such as the fire department or a hazardous material (HAZMAT) removal team, to stabilize the scene before entering.",
        "Lockout/Tagout Procedures": "Be sure to observe lockout/tagout procedures. Lockout/tagout refers to a set of procedures and practices that safeguard against the unexpected startup of machinery and equipment, or the possible release of hazardous energy when machinery is being maintained. The individual using the machinery turns off and disconnects it from its energy source before performing maintenance, and an authorized employee either locks or tags the energy-isolating device to prevent inadvertent release of energy. Machinery that is on and/or that might be leaking fuel or hydraulic fluid should not be approached. An agricultural storage area should not be entered alone.",
        "Working in Confined Spaces": "Working in confined spaces is another safety concern. A confined space is one with restricted openings for entry and exit, poor ventilation with possible air contaminants, and physical hazards related to engulfment (being surrounded and overwhelmed by a substance such as soil or grain) or collapse. Such scenes might include pits, tunnels, storage tanks, sewers, ventilation and exhaust ducts, underground utility vaults and pipelines.",
        "Guidelines for Confined Space Entry": "A responder who is required to enter a confined space should follow these guidelines:\n\uf0a7 An emergency rescue involving entry into a confined space must never be attempted without training in safe confined space entry and rescue procedures.\n\uf0a7 Assume a confined space is hazardous.\n\uf0a7 A person qualified to do so must ensure that structures are safe from collapse prior to anyone entering the confined space.\n\uf0a7 An attendant must be present immediately outside the space to provide help to the responder inside, and there must be a plan for emergency rescue.\n\uf0a7 There must be a safe method of communication between the responder inside the space and the attendant.\n\uf0a7 Appropriate PPE must be worn by the responder entering. Exact equipment is determined by the specific hazards encountered in the confined space (e.g., eye/face and head and foot protection, respiratory protection, safety belts, lifelines and harnesses).\n\uf0a7 Once a confined space has been identified, warning signs should be posted and, when possible, the entry physically blocked.\n\uf0a7 The conditions must be tested prior to entry and continuously monitored during entry. Testing must be performed by someone who is properly trained and has the appropriate equipment; one\u2019s senses should never be trusted to determine if the air in a confined space is safe. Many toxic gases and vapors cannot be seen or smelled. This is also not a reliable way to determine if sufficient oxygen is present.\n\uf0a7 Adequate air conditions must be maintained in the confined space, through proper ventilation.\n\uf0a7 If safe atmospheric conditions cannot be maintained, the absolute necessity of entering should be evaluated. If it is necessary to enter, an appropriate respirator must be worn, and this equipment must be evaluated by someone with the proper training to do so.\n\uf0a7 Properly trained workers must control utilities prior to entry into confined spaces, including, for example, electrical services, gas, propane, water, sanitary systems, communications and any secondary service systems.\n\uf0a7 If an unsafe condition develops, the space should be exited immediately.",
        "Agricultural Emergencies": "On an agricultural site, the combination of long hours, powerful mechanized equipment that may or may not be properly maintained and remote locations can be deadly. Expect severe trauma, patients left unfound for hours and a high incidence of spinal injury.",
        "Typical Injuries": "On an agricultural site, injuries most often involve the hands and arms, which can get caught in machinery. The most common injuries include:\n\uf0a7 Abrasions.\n\uf0a7 Amputations.\n\uf0a7 Animal bites.\n\uf0a7 Avulsions.\n\uf0a7 Burns.\n\uf0a7 Concussions.\n\uf0a7 Contusions.\n\uf0a7 Eye injuries.\n\uf0a7 Fractures.\n\uf0a7 Lacerations.\n\uf0a7 Punctures.\n\uf0a7 Sprains.\n\uf0a7 Strains.",
        "Working with the Equipment": "Injuries associated with different types of machinery each involve a different approach. It is important to have a basic understanding of how each piece of equipment works and how it can cause harm in order to avoid injuries to yourself or further injury to the patient. Before trying to extricate a patient from agricultural equipment, the equipment must be stabilized and shut down. If necessary, call a specialized crew to do this. As a general principle, agricultural equipment can be stabilized by blocking or chocking the wheels, putting on the parking brake or tying the equipment to another vehicle. The equipment should be shut down by entering the cab to access the main controls. The engine should be slowed down with the throttle and then the machine switched off using the ignition key. Some diesel-powered machines are shut down via an air shut-off lever rather than an ignition key. The engine can also be shut off by shutting the fuel line. This is done using the shut-off valve at the bottom of the fuel tank or using vice-grip pliers. If a diesel engine cannot be shut down and the patient is in a life-threatening situation, a 20-pound CO2 fire extinguisher can be emptied into the air intake. This will shut down the engine but will also cause considerable damage. Never touch a control on a piece of agricultural machinery unless you are sure you know what it does.",
        "Tractors": "Be aware that tractors can be fueled by diesel, gasoline or propane, and that fuel leaks, fires and explosions are a real possibility. Tractors often cause injuries by rolling over onto the rider. Do not approach the site until the tractor has been stabilized. A patient trapped by a tractor can be freed by digging a trench underneath the patient\u2019s body or by cutting off a piece of the machine, such as the steering wheel. In some cases, however, the tractor may need to be lifted off the patient by a specialized team.",
        "Combines": "Some common trouble spots on a combine include the auger, which is the rotating part of the screw conveyor; the heads, with their oscillating cutting bars; the reels, steel tines that can impale someone; and the snapping rollers, which can cause crush injuries.The reverse feature should never be used in an attempt to extricate a patient from a combine. The safest approach is to keep the machinery from moving, so pry bars and other tools should be used to jam the moving parts into place before beginning extrication. The hydraulic system must be locked. Usually a bar near the hydraulic cylinder will lock the header. If possible, the combine header should be divided from the drive mechanism. An acetylene torch can be used to cut pieces of the combine to free a patient, but the combine and surrounding soil should first be washed down and the inside of the combine flushed, to reduce the risk of fire. If a patient is trapped in the auger, the auger may need to be first cut free, and it should be transported with the patient. First, a large pipe wrench should be wedged on the shaft to prevent it from reversing, and then the auger drive disconnected. No attempt should be made to extricate a patient in the field if the auger has caused an avulsion. On older equipment, rescue tools can be used to spread snapping rollers, but this approach will not work on newer equipment.",
        "Hay Balers": "To free a patient caught in a hay baler, the tines may need to be disassembled by unscrewing the bolts holding it together. The drive belts that drive the cross auger or raise the auger may need to be disassembled with rescue tools. To prevent reverse motion, a pipe wrench can be used to hold on to the input shaft as the auger is cut free. To release a patient from the smooth rollers, the mounting bolts at each end should be removed, to remove the bearings. An acetylene torch should never be used to take apart a hay baler, as the combustible dust inside the baler may ignite.",
        "Other Areas": "In addition to the fields, agricultural emergencies may occur in silos, manure storage devices and places where livestock are held. Each of these areas carries its own hazards.",
        "Silos": "The major hazard in a silo is the gas formed during fermentation of stored crops, which, when inhaled, can kill within minutes. Keep in mind that \u201csilo gas\u201d can leak out to the surrounding area. Signs of this gas include a bleach-like smell, the presence of dead birds and insects, a yellowish or reddish vapor, and sick livestock nearby. A self-contained breathing apparatus (SCBA) must be worn to rescue a patient in the presence of silo gas. Administer supplemental oxygen to the patient, based on local protocols, and transport them as soon as possible.",
        "Manure Storage": "Manure is often flushed from livestock facilities into a holding pond or a closed structure. The hazards include toxic fumes and risk of drowning. To rescue a patient in a manure storage area, you must wear an SCBA and lifeline. Treat an immersed patient as you would a victim of drowning. If the patient is breathing, connect the patient to an SCBA. Also administer supplemental oxygen, based on local protocols. Before transporting the patient, remove any contaminated clothing and flush the patient\u2019s body with water. Do not bring any contaminated materials into the transport vehicle. Anyone and everything that came into contact with manure will require decontamination.",
        "Livestock": "Never enter an area with unsecured livestock. Treat injuries inflicted by livestock as you would any similar injury, but be sure to flush animal feces from any wound.",
        "Chemicals Used in Farming": "Many types of chemicals, particularly pesticides and fertilizers, are used in farming. Use protective clothing before entering a scene that may contain pesticides or other chemicals. If necessary, call a HAZMAT removal team. If you know what pesticide was involved in a particular emergency, check the label for instructions and precautions, and take the label with you to the hospital. Before transporting a patient, remove all clothing and flush the patient\u2019s body with water.",
        "Industrial Emergencies": "The hazards of industrial emergencies often mimic those of agricultural emergencies and include exposure to gases, fumes or other chemicals and to unstable machinery. The specific hazards depend on the site.",
        "Industrial Emergencies - Scene Size-Up and Safety": "Once again, it is important to size up the scene and not enter it until it has been secured. Keep in mind that even small industrial sites, such as newspaper printers and garages, may present significant hazards. These may include dangerous equipment and machinery, hazardous materials, a risk of explosion or fire, and confined spaces. When responding to the scene of an industrial emergency, determine whether there are hazardous materials present at the scene before entering. Communicate with staff about potential hazards, especially if you are unfamiliar with the operations. Determine if more than one patient is ill or has been injured, and if so, how many. Also determine the type of environment in which the emergency occurred: was it on the main level, in an elevated location or in a confined space? Once you have performed the scene size-up, communicate with safety or management personnel at the site, prior to entering the scene. Call for any specialized teams that may be needed, for example, to manage hazardous materials. Find out if the site has an emergency plan and whether or not that plan has already been activated. Also initiate the incident command system. Always ensure your safety and that of others in the area before entering the scene.",
        "Safety Equipment and Guidelines": "Before attempting a rescue in an industrial site, locate and speak to the industrial safety or management personnel. They can guide you through the emergency protocols that should be in place at every industrial site.",
        "Equipment": "Hazardous equipment that you may find at industrial sites includes all types of dangerous chemicals and machinery. Chemicals can cause toxic inhalations or absorptions, as well as burns. Be sure to use proper protective gear any time you approach a scene that is suspected of being contaminated with toxic chemicals.\nDangerous types of machinery include presses, hoists, conveyors and crushing devices. As with agricultural emergencies, never approach any equipment that has not been stabilized and shut down. Enlist the help of the safety or management personnel to properly stabilize and shut down machinery.",
        "Dangerous Locations": "Dangerous locations on industrial sites include trenches and confined spaces, especially if there are toxic chemicals that can collect there, and elevated locations. A confined space should not be entered until the need for an SCBA has been determined and the possible risk of collapse has been evaluated by a person trained to do so. Sick or injured people in elevated (aboveground) locations may require rescue by specialized high-angle rescue teams.",
        "Chemicals": "A wide range of industrial chemicals is used across various industries and may be found in a gas, aerosol, liquid or solid state. These chemicals can be hazardous either because of the chemicals they contain (e.g., carcinogens, reproductive hazards, corrosives, or agents that affect the lungs or blood) or because of their physical properties (e.g., flammable, combustible, explosive or reactive). Large quantities of these chemicals are present throughout the United States and may pose a risk because of exposure through either routine use or through acts of terrorism. If these hazardous chemicals are released, they could have extremely serious effects on exposed individuals.\nIn any of their states (gas, aerosol, liquid or solid), these toxic industrial chemicals could enter the body by being inhaled, absorbed through the skin or ingested. The time it takes for these substances to have an effect depends mainly on the route they use to enter the body. Generally, poisoning occurs more quickly if the chemical enters the body through the lungs. Safety Data Sheets (SDS) or chemical information cards will provide information on the effects of each chemical on humans and the symptoms of exposure.\nIf you or someone you are helping is exposed to a toxic industrial chemical, get yourself and the patient away from the area as quickly as you can. Avoid passing through the contaminated area, if possible. Employers should have an effective plan in place to assist employees in reaching shelter safely. They may be required to \u201cshelter-in-place\u201d if they cannot get out of a building or if the nearest place with clean air is indoors. Health and safety plans should take into account the possible impact of a release of toxic industrial chemicals. Plans should include guidelines such as monitoring, detection, awareness training, PPE, decontamination and medical surveillance of acutely exposed workers.\nResponders may have available to them a wide variety of direct reading instruments, as well as procedures for analytical sampling and analysis, to detect toxic industrial chemicals. During or after a toxic chemical release, and if the duration of the chemical release or airborne concentration of chemicals is unknown, Occupational Safety and Health Administration (OSHA) PPE Level B protection should be considered a minimum. Level B requires the highest level of respiratory protection but a lower level of skin protection. Required equipment would include an SCBA, hooded chemical-resistant clothing, special gloves, boots with covers and a hard hat."
    },
    {
        "KEY TERMS": "Cerebrospinal fluid: A clear fluid that flows within the ventricles of the brain, and around the brain and spinal cord., Cervical collar: A commercially produced rigid device that is positioned around the neck to limit movement of the head and neck; also called a C-collar., Concussion: A temporary loss of brain function caused by a blow to the head; considered a traumatic brain injury (TBI)., Manual stabilization: A technique used to achieve spinal motion restriction by manually supporting the patient\u2019s head and neck in the position found without the use of any equipment., Spinal column: The series of vertebrae extending from the base of the skull to the tip of the tailbone (coccyx); also referred to as the spine., Spinal cord: A cylindrical structure extending from the base of the skull to the lower back, consisting mainly of nerve cells and protected by the spinal column., Spinal motion restriction (SMR): A collective term that includes all methods and techniques used to limit the movement of the spinal column of a patient with a suspected spinal injury., Traumatic brain injury (TBI): An injury to the brain resulting from an external force such as a blow to the head or a penetrating injury to the brain; TBIs are associated with temporary and/or permanent impairment to brain function, including physical, emotional and cognitive functioning; a concussion is a common type of TBI.",
        "INTRODUCTION": "Although injuries to the head, neck and spine account for only a small percentage of all injuries, they are the cause of a significant number of fatalities annually. Traumatic brain injury (TBI)  alone accounts for about 30 percent of all injury deaths and approximately 2.5 million emergency department visits a year in the United States. Falls are the leading cause of TBI and other head, neck and spinal injuries, with a large percentage occurring in children up to 14 years of age and adults over the age of 65. Being struck by an object is the second leading cause of TBI, followed by motor-vehicle collisions. Other causes of head, neck and spinal injuries include sports-related mishaps, incidents related to recreational activities and violent acts such as assault.\nSurvivors of serious head, neck and spinal injuries have a wide range of physical and mental impairments, including paralysis, speech and memory problems, and behavioral disorders. Fortunately, prompt, appropriate care can help minimize the damage from most head, neck and spinal injuries. In this chapter, you will learn how to recognize when a head, neck or spinal injury may be serious. You will also learn how to provide appropriate care to minimize these injuries.",
        "ANATOMY OF THE HEAD, THE NECK AND THE SPINE": "The head contains special sense organs (e.g., eyes, nose and ears), the brain, mouth and related structures. The head is formed by the skull and the face. The four flat bones of the skull are fused together to form a hollow shell. This shell, known as the cranial cavity, contains the brain. The face is on the front of the skull. The bones of the face include the bones of the cheek, forehead, nose and jaw.\nThe neck contains the esophagus, larynx and part of the trachea. It also contains major blood vessels, muscles and tendons, and the cervical bones of the spine.\nThe back is made up of soft tissue, bones, cartilage, nerves, muscles, tendons and ligaments. It supports the skull, shoulder bones, ribs and pelvis, and protects the spinal cord and other vital organs.",
        "INJURIES TO THE HEAD-Head Injurie": "The head is easily injured because it lacks the padding of muscle and fat that are found in other areas of the body. The most common cause of death in patients with head injuries is a lack of oxygen to the brain. Also, swelling of the brain tissues or bleeding within the brain can cause increased pressure inside the skull that, in turn, can cause damage to the brain. A brain injury may lead to altered consciousness with airway and breathing problems. The two types of head injury are open and closed.",
        "Open Head Injuries": "Open head injuries involve a break in the skull or occur when an object penetrates the skull. There is direct damage to the skull, and brain damage may be involved. Head injuries bleed profusely, and a patient may lose blood quickly. With open head injuries, it is important that you:\n\uf0a7 Control bleeding promptly with dressings, direct pressure and a pressure bandage, while limiting spinal movement.\n\uf0a7 Do not apply direct pressure over where there is an obvious skull fracture or depression.\n\uf0a7 Do not remove any penetrating object; instead stabilize it with thick dressings.",
        "Closed Head Injuries": "Closed head injuries occur when the brain is struck against the skull but the skull remains intact. They can also occur from impact with a blunt object. This type of injury may be more challenging to detect as there may not be any visible damage to the skull although, in some cases, swelling or a depression is evident. In addition to the general signs of head injury, there may be a softness or depression on the skull and blood, or cerebrospinal fluid  may be leaking from the nose or ears. If you suspect a closed head injury, do not control bleeding using direct pressure, as this could cause further injury by pushing bone fragments into the brain. Because of the rigid nature of the skull, if swelling or bleeding in the brain occurs, brain damage may occur depending on the nature and force of the injury.",
        "Skull Fractures": "You should suspect a skull fracture any time there has been significant trauma to the head, even if the patient has suffered a closed head injury. Skull fractures may be accompanied by brain damage, caused by bleeding or swelling within the brain, which is a life-threatening condition. If the patient is showing any of the signs of head injury, a skull fracture may be present and brain injury is possible. A patient with a skull injury should be seen by a more advanced medical professional immediately. The signs and symptoms of a skull fracture with brain injury include: \uf0a7 Damage to the skull, including deformity to the skull or face. \uf0a7 Pain or swelling at the site of injury. \uf0a7 Blood or other fluids leaking from the mouth, nose, ears or scalp wound. \uf0a7 Unequal facial movements; drooping, unequal or unresponsive pupils; or vision problems in one or both eyes. \uf0a7 Bruising around the eyes (\u201craccoon eyes\u201d). \uf0a7 Bruising behind the ear (\u201cBattle\u2019s sign\u201d).",
        "Concussion": "A concussion  is a common type of traumatic brain injury that involves a temporary loss of brain function. Concussions are particularly common sports-related injuries, but they can occur whenever a person experiences a bump, blow or jolt to the head or body that results in rapid movement of the head. A patient who has had one concussion is at increased risk for subsequent concussions. A concussion can result from even a seemingly minor bump, blow or jolt and may be tricky to recognize. Many patients who experience a concussion do not lose consciousness, or they may only lose consciousness very briefly. Your best clues that a patient may have a concussion are often changes in their behavior noted after they have experienced a bump, blow or jolt. For example, the patient may seem confused, dazed or stunned; lose the ability to remember or follow simple instructions; or ask repeatedly what happened. The patient may complain of a headache, feel nauseated or vomit, have blurred or double vision, complain of dizziness, or be especially sensitive to light or noise. Many patients who have experienced a concussion say that the concussion caused them to feel \u201csluggish,\u201d \u201cgroggy\u201d or just \u201cnot right.\u201d Signs and symptoms of a concussion usually are apparent soon after the injury, although some can appear hours or days later. For example, the patient may sleep more or less than usual. Children may show changes in playing or eating habits. The effects of the concussion can last for several days, weeks or longer. If you think that a patient has sustained a concussion, advise them to stop the activity they were engaged in when the incident occurred. The patient should follow up with a healthcare provider for a full evaluation. A healthcare provider is best able to evaluate the severity of the injury and make recommendations about when the patient can return to normal activities. And, while rare, permanent brain injury and death are potential consequences of failing to identify and respond to a concussion in a timely manner.",
        "CRITICAL FACTS": "The head is easily injured because it lacks the padding of muscle and fat that are found in other areas of the body. Open head injuries involve a break in the skull or occur when an object penetrates the skull. There is direct damage to the skull, and brain damage may be involved. Closed head injuries occur when the brain is struck against the skull but the skull remains intact. They can also occur from impact with a blunt object. You should suspect a skull fracture any time there has been significant trauma to the head, even if the patient has suffered a closed head injury. A concussion is a temporary loss of brain function caused by a blow to the head. It is considered a brain injury, although there may be no detectable damage to the brain.",
        "Penetrating Wounds": "If an object such as a bullet, knife or nail passes through the skull and lodges in the brain, it is considered a penetrating wound. Penetrating wounds can cause long-term damage. Do not try to remove an object that is impaled in the skull. Stabilize the object and the wound site with bulky dressings, and then dress the surrounding area with sterile gauze. If you suspect an object has penetrated the skull, but it is not visible, cover the area lightly with sterile dressings. Never apply firm, direct pressure to a head injury that shows bone fragments, exposed brain tissue or where a depression is visible. Do not stop the flow of blood or cerebrospinal fluid draining from the ears or nose. Apply loose gauze dressings. Keep the patient still and minimize movement of the head and neck.",
        "Signs and Symptoms of a Concussion": "THINKING AND REMEMBERING: Difficulty thinking clearly; Difficulty remembering events that occurred just prior to the incident and just after the incident; Difficulty remembering new information; Difficulty concentrating; Feeling mentally 'foggy'; Difficulty processing information. PHYSICAL: Headache; Blurry vision; Nausea or vomiting; Dizziness; Sensitivity to noise or light; Balance problems; Feeling sluggish (lack of energy). EMOTIONAL: Irritability; Sadness; Heightened emotions; Nervousness or anxiety. BEHAVIORAL: Changes in sleeping habits (sleeping more or less than usual, difficulty falling asleep); Changes in playing and eating habits (in children).",
        "Scalp Injuries": "Scalp bleeding can be minor or severe. A scalp injury may bleed more than expected due to the large number of blood vessels in the scalp. The bleeding is usually easily controlled with direct pressure. Because the skull may be injured, be careful to press gently at first. If you feel a depression, a spongy area or bone fragments, do not put direct pressure on the wound. Attempt to control bleeding with pressure on the area around the wound. Examine the injured area carefully because the patient\u2019s hair may hide part of the wound. If you are unsure of the extent of the scalp injury, summon more advanced medical personnel who will be better able to evaluate the injury. Severe bleeding from the scalp can cause shock in young children and infants. Once bleeding is controlled, apply several dressings and hold them in place with a gloved hand. Secure the dressings with a roller bandage. Use a pressure bandage if necessary.",
        "Signs and Symptoms of Head and Brain Injury": "Some of the typical signs and symptoms of head and brain injury include the following:\n\uf0a7 Damage to the skull, including deformity to the skull or face\n\uf0a7 Pain or swelling at the site of the injury\n\uf0a7 Irregular breathing\n\uf0a7 A sudden, debilitating headache\n\uf0a7 Nausea or vomiting\n\uf0a7 Incontinence (involuntary urination or defecation)\n\uf0a7 High blood pressure and slowed pulse\n\uf0a7 Paralysis or droopiness, often on one side of the body; rigidity of limbs\n\uf0a7 Loss of balance\n\uf0a7 Asymmetrical facial movements\n\uf0a7 Confusion, unresponsiveness or other type of altered mental state\n\uf0a7 Facial bruising, including \u201craccoon eyes\u201d (visible bruising around the eyes)\n\uf0a7 External bleeding of the head\n\uf0a7 Unusual bumps or depressions on the head\n\uf0a7 Blood or other fluids draining from the ears, mouth or nose\n\uf0a7 Bruising behind the ears (\u201cBattle\u2019s sign\u201d)\n\uf0a7 Unequal pupil size and unresponsive pupils; disturbance of vision in one eye or both\n\uf0a7 Speech problems\n\uf0a7 Seizures",
        "Head and Brain Injury - Providing Care": "Your first step should be to summon more advanced medical care. Making sure to follow standard precautions to prevent disease transmission, provide the following care while waiting for more advanced medical personnel to arrive:\n\uf0a7 Establish manual stabilization of the head and neck, perform a primary assessment and maintain manual stabilization while at the scene.\n\uf0a7 Maintain an open airway. Monitor the airway, suction if needed and administer supplemental oxygen, based on local protocols.\n\uf0a7 Control any bleeding and apply dressings to any open wounds.\n\uf0a7 Do not apply direct pressure if there are any signs of an obvious skull fracture.\n\uf0a7 If there is leaking of cerebrospinal fluid from the ears or a wound in the scalp, cover the area loosely with a sterile gauze dressing.\n\uf0a7 Do not attempt to remove any penetrating object; instead stabilize it with a bulky dressing.\n\uf0a7 Maintain manual stabilization until other emergency medical services (EMS) responders relieve you. If you are trained to do so and protocols allow, apply a cervical collar (also called a C-collar).\n\uf0a7 Monitor the patient\u2019s vital signs and mental status closely, and watch for any changes in the patient\u2019s status.\n\uf0a7 Try to calm and reassure the patient. Encourage the patient to engage in conversation with you; it may prevent loss of consciousness.",
        "Nosebleed": "Nose injuries often result from a blow by a blunt object. A broken nose may be deformed and will swell. Nosebleeds can also be caused by dryness and high blood pressure. Nosebleeds can be painful or the nose may be tender, there can be bleeding only from the nose or the patient could vomit swallowed blood. If the patient is unresponsive, the airway can become blocked by blood. Care for soft tissue injuries to the nose as you would other soft tissue injuries. Apply cold packs to reduce swelling and take special care to maintain an open airway. You can usually control bleeding by having the patient sit with the head slightly forward while pinching the nostrils together for about 10 minutes. Advanced medical care is needed if the bleeding does not stop, recurs or the patient has a history of high blood pressure. Tell the patient not to sniffle or blow their nose. If the patient loses consciousness, place the patient in a side-lying recovery position to allow the blood to drain away from the airway. Children may have objects in the nose. Do not attempt removal, as special lighting and instruments are required. Reassure the child and parent, and call for more advanced medical personnel.",
        "Eye Injuries": "Injuries to the eye can involve the eyeball, the bone and the soft tissue surrounding the eye. Blunt objects, like a fist or a baseball, may injure the eye and surrounding area, or a smaller object may penetrate the eyeball. Care for open and closed wounds around the eye as you would for any other soft tissue injury. Injuries to the eyeball itself require different care. Injuries that penetrate the eyeball or cause the eye to be removed from its socket are very serious and can cause blindness. Never put direct pressure on the eyeball. Remember that all eye injuries should be examined by a healthcare provider. It is not necessary to cover both the injured and the uninjured eyes, because sympathetic or involuntary eye movement occurs even when both eyes are covered and not exposed to outside stimuli. Covering both eyes can also cause fear and increase anxiety, especially in children, and pose a safety risk to the patient, but follow local protocols or, if in doubt, contact medical control.",
        "Head and Brain Injury - Assessment": "To assess what type of care the patient will need, first determine when the injury occurred, whether one or both eyes were injured, and when the patient first noticed the symptoms. Then, using a small penlight, follow these guidelines: \uf0a7 Check the eye sockets and eyelids for bruising, lacerations, swelling or deformity. \uf0a7 Check the whites of the eyes for foreign objects, discoloration or discharge. \uf0a7 Check that the eyes can move in all directions, and that the pupils react equally to light. Ensure that there is no pain when the eyes move. \uf0a7 Check that the pupils are equal in size. \uf0a7 Check that there are no lacerations or foreign objects in the eyeballs.",
        "CRITICAL FACTS 2": "There are numerous signs and symptoms of head or brain injury, including irregular breathing, high blood pressure and slowed pulse, loss of balance, external bleeding of the head, bruising behind the ears and seizures\u2014among others. To provide care for a head injury, maintain an open airway and manual stabilization until other emergency medical services (EMS) responders relieve you. Nose injuries often result from a blow by a blunt object. A broken nose may be deformed and will swell. Nosebleeds can also be caused by dryness and high blood pressure.",
        "Foreign Bodies": "Foreign bodies that get in the eye, such as dirt or slivers of wood or metal, are irritating, painful and can cause significant damage to the cornea. It is important to tell the patient not to rub the eyes. Never touch the eye and always follow standard precautions when caring for the patient. If you determine there is a foreign body in the eye, try to remove it by telling the patient to blink several times. If the object is visible on the lower eyelid, pull the eyelid down and try to remove the object with the corner of a sterile gauze pad. Be careful not to touch the eyeball. Next, gently flush the eye with irrigation/saline solution or water. After irrigating, if the object is visible on the upper eyelid, gently roll the upper eyelid back over a cotton swab and attempt to remove the object with the corner of a sterile gauze pad, being careful not to touch the eyeball. If the object remains, the patient should receive advanced medical care. Cover the injured eye with an eye pad/shield.",
        "Chemical Exposure to the Eye": "If chemicals have been in contact with the patient\u2019s eyes, irrigate the affected eye or eyes with clean water for at least 15 minutes. If only one eye is affected, make sure you do not let the water run into the unaffected eye. If water is not available, you can use sterile saline. Continue care while transporting the patient, if you can.",
        "Impaled Objects": "Do not attempt to remove an object that is impaled in the eye. Keep the patient in a face-up position and enlist someone to help stabilize the patient\u2019s head. Stabilize the object by encircling the eye with a gauze dressing or soft sterile cloth, being careful not to apply any pressure to the area. Position bulky dressings around the impaled object, such as roller gauze, and then cover it with a shield such as a paper cup. Do not use Styrofoam\u00ae-type materials, as small particles can break off and get into the eye. The shield should not touch the object. Bandage the shield and dressing in place with a self-adhering bandage and roller bandage covering the patient\u2019s injured eye, to keep the object stable and minimize movement. Comfort and reassure the patient. Do not leave the patient unattended.",
        "CRITICAL FACTS 3": "Do not attempt to remove an object that is impaled in the eye. Keep the patient in a supine position and enlist someone to help stabilize the patient\u2019s head.",
        "Oral Injuries": "Patients with facial injuries may have injuries to their teeth or jaws. Situations that fracture or dislocate the jaw can also cause head, neck or spinal injuries. Maintaining an open and clear airway and restricting spinal motion should be priorities. The signs and symptoms of oral injuries include: \uf0a7 Teeth that do not meet or are uneven, loose or missing. \uf0a7 A patient who is unable to open or close the mouth. \uf0a7 Saliva mixed with blood. \uf0a7 Pain in areas around the ears. \uf0a7 Difficulty or pain when speaking. If the patient is bleeding from the mouth, and a head, neck or spinal injury is not suspected, place the patient in a seated position with the head tilted slightly forward or on their side in a recovery position to allow any blood to drain from the mouth. If the injury has penetrated the lip, place a rolled dressing between the lip and the gum and another dressing on the outer surface of the lip. If the tongue is bleeding, apply a dressing and direct pressure. A cold pack may alleviate pain and swelling. If a tooth is knocked out, control the bleeding by placing a rolled gauze pad into the space left by the missing tooth and have the patient gently bite down to maintain pressure. Try to locate and save the tooth, because a dentist or other healthcare provider may be able to reimplant it. Place the tooth in Hanks\u2019 Balanced Salt solution (e.g., Save-A-Tooth\u00ae), if available. If you do not have Hanks\u2019 Balanced Salt solution, place the tooth in egg white, coconut water or whole milk. If these are not available, place the tooth in the injured patient\u2019s saliva. Be careful to pick up the tooth only by the crown (the part of the tooth that is normally visible above the gum line) rather than by the root. The patient should seek dental or emergency care as soon as possible after the injury. The sooner the tooth is reimplanted, the better the chance that it will survive. Ideally, reimplantation should take place within 30 minutes. Leave intact dentures in position to support the mouth structure. Remove broken dentures and send them with the patient to assist the oral surgeon with jaw alignment.",
        "INJURIES TO THE NECK AND SPINE": "Injuries to the neck or spine can damage both bone and soft tissue, including the spinal cord. It is difficult to determine the extent of damage in neck or spinal injuries. Since generally only X-rays, computerized tomography (CT or CAT) scans or magnetic resonance imaging (MRI) scans can show the severity of these injuries, you should always care for them as if they are serious.",
        "Mechanism of Injury": "Consider the possibility of a serious neck or spinal injury in a number of situations. These may include: \uf0a7 Any injury caused by entry into shallow water. \uf0a7 Injury as a result of a fall greater than a standing height. \uf0a7 An injury involving a diving board, water slide or entering water from a significant height, such as an embankment, cliff or tower. \uf0a7 Any injury, such as from a car or other vehicle collision, involving severe blunt force to the person\u2019s head or trunk. \uf0a7 A motor-vehicle, motorized cycle or bicycle collision involving a pedestrian or driver or passengers not wearing safety belts, or one that results in a broken windshield or a deformed steering wheel. \uf0a7 Injury as the result of a hanging. \uf0a7 Any unresponsive trauma patient. \uf0a7 Injury involving a penetrating trauma to the head, neck or torso. \uf0a7 Any person thrown from a motor vehicle. \uf0a7 Any injury in which a patient\u2019s industrial hard hat or helmet is broken, including a motorcycle, bicycle, football or other sports helmet. \uf0a7 A person who has other painful injuries, especially of the head and neck. \uf0a7 A person complaining of neck or back pain or tenderness, tingling in the extremities or weakness. \uf0a7 An injured person who appears to be frail. \uf0a7 A person who is not fully alert or appears to be intoxicated. \uf0a7 Someone with an obvious head or neck injury. \uf0a7 Sensory deficit or muscle weakness involving the torso or upper extremities. \uf0a7 Children less than 3 years of age with evidence of head or neck trauma.",
        "Lacerations of the Neck": "The carotid artery and jugular vein are both located in the neck, and injuries to one or both will produce serious, possibly fatal bleeding. An open wound in the neck may result in an air embolism, which is caused by air being sucked into the wound. A fractured larynx or collapsed trachea is also a common neck injury. If the laceration is caused by an object impaled in the neck, do not attempt to remove it.",
        "Signs and Symptoms of Neck and Spinal Injuries": "The signs and symptoms of neck injuries may include: \uf0a7 Obvious lacerations, swelling or bruising. \uf0a7 Objects impaled in the neck. \uf0a7 Profuse external bleeding. \uf0a7 Impaired breathing as a result of the injury. \uf0a7 Difficulty speaking or complete loss of voice. \uf0a7 A crackling sound when the patient is speaking or breathing, due to air escaping from an injured trachea or larynx. \uf0a7 An obstructed airway caused by swelling of the throat. The signs and symptoms of spinal injuries may include: \uf0a7 Pain or pressure in the back, independent of movement or palpation. \uf0a7 Tenderness in the area of the injury. \uf0a7 Pain associated with moving. \uf0a7 Numbness, weakness, tingling, or loss of feeling or movement in the extremities. \uf0a7 Partial or complete loss of movement or feeling below the suspected level of injury. \uf0a7 Difficulty breathing or shallow breathing. \uf0a7 Loss of bladder and/or bowel control. If the patient can walk, move and has feeling in the arms and legs, it does not necessarily rule out the possibility of injury to the bones of the spine or to the spinal cord.",
        "CRITICAL FACTS 4": "Injuries to the neck or spine can damage both bone and soft tissue, including the spinal cord. It is difficult to determine the extent of damage in neck or spinal injuries. Always care for these types of injuries as if they are serious. You should suspect possible serious neck or spinal injury in many situations, including but not limited to diving board mishaps, motor-vehicle crashes where a person has been thrown from the vehicle, and situations where hard hats or helmets have been broken.",
        "Neck and Spinal Injuries - Providing Care": "If you suspect a patient has a neck or spinal injury, restrict spinal motion and control any bleeding. Do not move the patient or ask the patient to move to try to find a pain response. It is essential when treating neck injuries to maintain an open airway. If the patient is wearing a helmet, do not remove it unless you have been trained to do so and have the appropriate resources, or unless it is necessary to access and assess the patient\u2019s airway. Because movement of an injured neck or spine can irreversibly damage the spinal cord, keep the patient still. To restrict spinal motion initially, use manual stabilization with your hands or knees. Perform a primary assessment on the scene while maintaining spinal motion restriction (SMR). Assess the patient\u2019s pulse, movement and feeling in the extremities. Approach patients from the front so they can see you without turning their heads, and tell patients to respond verbally to your questions. Ask the responsive patient the following questions, while maintaining SMR, to further assess the situation: \uf0a7 Does your neck or back hurt? \uf0a7 What happened? \uf0a7 Where does it hurt? \uf0a7 Can you move your hands and feet? \uf0a7 Can you feel where I am touching? For an unresponsive patient, maintain an open airway using the jaw-thrust (without head extension) maneuver and assist ventilation if needed. you should not attempt to align the head and neck with the body unless you cannot maintain an open airway, you need to remove a helmet or you need to assist with the application of a C-collar. Administer supplemental oxygen based on local protocols. While obtaining further information, maintain SMR of the head and neck in the position in which they were found. Obtain any further information from others at the scene to determine the mechanism of injury and the patient\u2019s mental status before your arrival. Keeping the head, neck and spine from moving (spinal motion restriction ) helps prevent further damage to the spinal column . If a second responder is available, that person can provide care for any other conditions while you keep the head and neck stable. Assist more advanced medical personnel upon arrival by maintaining SMR. More advanced medical personnel will then apply a cervical collar to further assess the patient to determine the best way to prepare them for transport. If you must move the patient, secure the patient to a backboard or other extrication device prior to moving them. Backboards should be used only for extricating the patient from the scene and moving them to the ambulance, as evidence has shown that backboards are not beneficial for spinal cord injuries and can cause harm. Always follow local protocols when considering care for a suspected spinal injury.",
        "Helmet Removal": "When you encounter a patient who has sustained injuries while wearing a helmet, you must assess whether it is necessary to remove the helmet. As always, assess breathing and pulse and determine your course of action. Since properly fitted helmets fit snugly to the head, it is difficult to remove one without moving the patient\u2019s head and neck. Removing a helmet requires a minimum of two responders. When providing care to a patient with a helmet, you should only remove it if it is impeding your care, you are unable to access and assess the airway, or if the patient is in cardiac arrest. Otherwise, do not try to remove it. If the patient is breathing and the airway is clear, maintain SMR with the helmet in place. Consider the need to pad under the shoulders to maintain the airway in a neutral position. Additionally, both the helmet and the shoulder pads, if worn, should be removed to maintain the patient in a neutral position. Some helmets are closed in front with face protectors. If the protector cannot be lifted out of the way, it is preferable that it be cut off rather than the helmet removed. Situations that may require removing the helmet include those in which: \uf0a7 You cannot access or assess the patient\u2019s airway and breathing. \uf0a7 The airway is impeded and cannot be opened with the helmet on. \uf0a7 The patient is in cardiac arrest. \uf0a7 You cannot immobilize the spine. If a helmet is loose, this does not necessarily mean you must remove it. Try to stabilize the helmet by adding padding between the helmet and the patient\u2019s head.",
        "Preventing Head, Neck and Spinal Injuries": "While some injuries are unavoidable, many others are preventable by being aware of potential dangers in the environment and taking appropriate safety measures. To prevent head, neck and spinal injuries, take the following steps: \uf0a7 Know your risk. Be aware of your surroundings and wear appropriate safety equipment and protective devices such as padding, footwear, helmets and eye protection. \uf0a7 Do not dive into a body of water if you are unsure of the depth. \uf0a7 Wear your seat belt in a motor vehicle. Insist that passengers wear seat belts and always transport children in approved child safety seats in the back of the vehicle, according to state and local regulations. \uf0a7 To prevent head and neck injuries in rear-end collisions, properly adjust your motor vehicle\u2019s",
        "CRITICAL FACTS 6": "Backboards should be used only for extricating the patient from the scene and moving them to the ambulance, as evidence has shown that backboards are not beneficial for spinal cord injuries and can cause harm.",
        "PUTTING IT ALL TOGETHER": "In this chapter, you learned how to recognize and care for serious head, neck and spinal injuries. To decide whether an injury is serious, you must consider its cause. Often the cause is the best indicator of whether an injury to the head, neck or spine should be considered serious. You must also carefully assess the signs and symptoms. If you have any doubts about the seriousness of an injury, summon more advanced medical personnel. Like injuries elsewhere on the body, injuries to the head, neck and spine often involve both soft tissues and bones. Control bleeding as necessary, usually with direct pressure on the wound. With scalp injuries, however, be careful not to apply pressure to a possible skull fracture. With eye injuries, remember not to apply pressure on the eyeball. If you suspect that the patient may have a serious head, neck or spinal injury, minimize movement of the injured area when providing care. Minimizing movement is best accomplished by providing spinal motion restriction using manual stabilization (Skill Sheet 23-4). Apply a cervical collar and secure the patient to a backboard or other extrication device if you must move the patient from the scene to the ambulance, you are trained to do so and local protocols allow. Many injuries are preventable if simple safety precautions are followed. Know your risks and mitigate your danger of injury.",
        "Removing Helmets and Other Equipment": "If you determine that it is necessary to remove a helmet from a patient to provide care, you must do so correctly to avoid causing further harm to the patient. Helmets fall into multiple categories including sports helmets and motorcycle helmets. Sports helmets usually have an opening in front, which allows for easier access to the airway. You can usually remove the face mask on a football helmet by cutting the plastic clips with pruning shears or using a screwdriver to unscrew the clips. Avoid trying to unsnap or manipulate the clips as it may cause unnecessary movement of the head and neck. It is more difficult to access the airway with a motorcycle helmet in place, as they usually cover the full face and the airway. The steps for a non-athletic helmet removal require two responders and are as follows: 1. If the patient is wearing glasses, remove them first before attempting helmet removal. 2. The first responder applies stabilization by holding both sides of the helmet, with fingers on the patient\u2019s lower jaw. This will prevent the helmet from moving around if the strap is loose. 3. The second responder loosens the strap at the D-rings while the first responder maintains manual stabilization. 4. The second responder then places one hand on the patient\u2019s mandible at an angle, with the thumb on one side, and the long and index fingers on the other. With the other hand, the second responder holds the back of the patient\u2019s head (occipital region). 5. The first responder then removes the helmet halfway, making sure to clear the ears, while the second responder readjusts hand position under the patient\u2019s head. The first responder then removes the helmet the rest of the way, making sure to tilt backward to avoid hitting the nose. 6. The second responder maintains manual stabilization throughout, from below, preventing head tilt. After the helmet has been removed, the first responder replaces the hands over the ears, taking over responsibility for stabilization. 7. The first responder maintains manual stabilization from above until a cervical collar can be applied. For an emergency medical responder (EMR), the removal of athletic equipment, such as football helmets, is usually more challenging than the removal of a motorcycle helmet. Unlike a motorcycle helmet, removal of a football, hockey or lacrosse helmet alone without removal of the athlete\u2019s shoulder pads increases the risk of cervical movement and further spinal injury. If an athlete is suspected of having a spinal injury, the helmet should only be removed when: \uf0a7 The face mask cannot be removed after a reasonable period of time to gain access to the airway. \uf0a7 The design of the helmet and chin strap, even in the absence of the face mask, does not allow for a controlled airway or adequate ventilation. \uf0a7 The design of the helmet and chin straps do not hold the head securely in place (immobilization of the helmet does not also immobilize the head). \uf0a7 The helmet prevents extrication of the patient for transport in an appropriate position. The face mask should be removed after an athlete is suspected of having a spinal injury, even if the patient is still conscious. A face mask is held in place using four loop-straps, two on the top and one on either side. Each of these loop-straps must be removed by one EMR while a second responder minimizes neck movement and maintains the neck in a neutral position. The loop-straps can be removed using a variety of tools such as a screwdriver, pruner shear and several other commercial devices designed specifically for this task. However, this is a skilled task, requiring practice. The two side loop-straps are removed first, followed by the two top loop-straps. Never use items such as razor blades, scalpels, or emergency medical technician (EMT) or trauma shears to remove the loop-straps, as these items increase the risk of injury to the athlete and the EMR and may delay removal of the face mask.To remove a helmet and shoulder pads, one EMR must provide manual stabilization while a second EMR cuts away the chin strap, shoulder pad straps and jersey. This is followed by removal of the internal cheek pads (using a tongue depressor) and deflating the helmet\u2019s air bladder system, if necessary (using a syringe or air pump), while another trained responder stabilizes the chin and back of the neck. Two to four other trained responders are placed at strategic locations along the body to support the shoulders, upper torso and other locations based on the size of the athlete. The athlete is lifted and the helmet is slid off the head by rotating the helmet in an anterior direction. Do not attempt to spread the helmet by the ear holes, as this will only tighten the helmet on the head causing further spinal movement and possible injury. Once the helmet is off, the shoulder pads are immediately removed by spreading apart the front panels and pulling them around the head. Remove any clothing or equipment under the shoulder pads. Lower the athlete back to the ground. Removal of protective equipment such as a football helmet and shoulder pads is a skilled technique, requiring hours of practice. It often requires a minimum of five responders trained in this skill. If this type of situation is encountered during an athletic event, look to the certified athletic trainer to assist in removal of the face mask, helmet and shoulder pads, as the necessary tools will be included in athletic emergency kits. Prior planning and interdisciplinary practice among the EMR, certified athletic trainer and emergency department personnel is recommended prior to the beginning of the athletic season, particularly for football.",
        "Cervical Collars and Backboarding": "A cervical collar (also called a C-collar) is a rigid device positioned around the neck to limit movement of the head and neck. Once you have spinal motion restriction (SMR), a rigid C-collar should be applied if local protocols and medical direction permit. This collar helps minimize movement of the head and neck and keeps the head in line with the body. Applying a C-collar requires two responders. While one responder maintains SMR, another carefully applies an appropriately sized C-collar. An appropriately sized collar is one that fits securely, with the patient\u2019s chin resting in the proper position and the head maintained in line with the body. Some C-collars come with specific manufacturer\u2019s instructions for proper sizing. Do not apply a C-collar in a circumstance in which you would not want to align the head with the body. Once a C-collar has been applied and SMR is maintained, the patient\u2019s entire body should be immobilized for extrication. This can be done using the following equipment:\n\uf0a7\tA backboard\n\uf0a7\tHead immobilizer\n\uf0a7\tStraps\nIf you do not have a backboard or other extrication device available, support the patient in the position in which the patient was found until more advanced medical personnel arrive. Once a C-collar is in place, the patient is positioned on a backboard or other device, such as a scoop stretcher. This is done by \u201clog rolling\u201d the patient onto the board. This technique keeps the head in line with the body. It requires a minimum of three responders: one to support the head and maintain SMR, and two others to position the backboard and roll the patient\u2019s body. However, it is highly preferable to have at least four responders available to perform this technique. One responder can provide SMR and the others can log roll the patient and position the backboard. Once the patient is on the board, use several straps to secure the patient\u2019s body to the backboard. There are several ways to apply the straps used to secure the patient onto the board. A common way is to secure the chest by crisscrossing the straps. Regardless of which method is used, the straps should be snug but not so tight as to restrict movement of the chest during breathing. With the remaining straps, secure the patient\u2019s hips, thighs and legs. Secure the hands in front of the body. Once the patient\u2019s body is secured to the backboard, secure the patient\u2019s head. If the patient\u2019s head does not appear to be resting in line with the body, you may need to place a small amount of padding, such as a small folded towel, to support the head. Normally, approximately 1 inch of padding is all that is needed to keep the head in line with the body and at the same time provide comfort for the patient. Next, use a commercially made head-immobilization device. Many of these devices use Velcro\u00ae straps to secure the head. You should follow the manufacturer\u2019s instructions when using these devices. Based on local protocols, patients may be removed from the backboard once they are placed on the ambulance stretcher. Remember that the purpose of the backboard is for extricating the patient from the scene and moving them to the ambulance. It is not for transportation to the hospital.",
        "Controlling Bleeding from an Open Head Wound": "NOTE: Always follow standard precautions when providing care, and summon more advanced medical personnel if necessary. STEP 1: Apply direct pressure. Place a sterile dressing or clean cloth over the wound and press gently against the wound with your hand. Do not put direct pressure on the wound if you feel a depression, spongy area or bone fragments. Press gently on the area around the wound. STEP 2: Elevate the body part. Elevate the head and shoulders unless you suspect an injury to the spine. STEP 3: Apply a pressure bandage. Using a roller bandage, cover the dressing completely, using overlapping turns. Tie or tape the bandage in place. If blood soaks through the bandage, leave the original dressing in place but remove and replace any additional dressings and bandages over the wound. STEP 4: If bleeding stops, determine if further care is needed. STEP 5: If bleeding does not stop, summon more advanced medical personnel.",
        "Caring for Foreign Bodies in the Eye": "NOTE: Tell the patient not to rub the eyes. Never touch the eye and always follow standard precautions when providing care. STEP 1: Remove the foreign object from the eye. Tell the patient to blink several times. If the object is visible on the lower eyelid, pull the eyelid down and try to remove the object with the corner of a sterile gauze pad. STEP 2: Gently flush the eye with water or irrigation/saline solution. STEP 3: If the object is visible on the upper eyelid, gently roll the upper eyelid back over a cotton swab and attempt to remove the object with the corner of a sterile gauze pad. NOTE: If the object remains, the patient should receive advanced medical care. Cover the injured eye with an eye pad/shield.",
        "Caring for an Impaled Object in the Eye": "NOTE: Do not attempt to remove an object that is impaled in the eye. Keep the patient in a face-up position and enlist someone to help stabilize the patient\u2019s head. Always follow standard precautions when providing care. STEP 1: Stabilize the object by encircling the eye with a gauze dressing or soft sterile cloth. Do not apply any pressure to the area. STEP 2: Position bulky dressings around the impaled object, such as roller gauze, and then cover it with a shield such as a paper cup. The shield should not touch the object. NOTE: Do not use Styrofoam-type materials. STEP 3: Bandage the shield and dressing in place with a self-adhering bandage and roller bandage. STEP 4: Comfort and reassure the patient. NOTE: Do not leave the patient unattended.",
        "Spinal Motion Restriction Using Manual Stabilization": "NOTE: Call for more advanced medical personnel for a head, neck or spinal injury, while minimizing movement of the head, neck and spine. Always follow standard precautions when providing care. STEP 1: Minimize movement by placing your hands on both sides of the patient\u2019s head. STEP 2: Support the head in the position found. NOTE: Do not align the head and neck with the spine if the head is sharply turned to one side, there is pain on movement or if you feel any resistance when attempting to align. Instead, gently maintain the position found. STEP 3: Maintain an open airway. Control any external bleeding and keep the patient from getting chilled or overheated. NOTE: Gently position the patient\u2019s head in line with the body if airway cannot be maintained, helmet must be removed, or a C-collar is needed.",
        "Immobilizing a Head, Neck or Spinal Injury": "NOTE: Call for more advanced medical personnel for a head, neck or spinal injury, while minimizing movement of the head, neck and spine. Always follow standard precautions when providing care. STEP 1: Apply spinal motion restriction. Place your hands on both sides of the patient\u2019s head. Gently position the head in line with the body, if necessary. Support the head in that position. NOTE: Do not align the head and neck with the spine if the head is sharply turned to one side, there is pain on movement or if you feel any resistance when attempting to align the head and neck with the spine. Instead, gently maintain the head and neck in the position found. STEP 2: Apply a cervical collar (C-collar). One responder maintains spinal motion restriction. A second responder applies appropriately sized C-collar (correct size as determined by manufacturer\u2019s instructions). STEP 3: Log roll the patient onto a backboard. One responder maintains spinal motion restriction of the head. Additional responders support the patient\u2019s shoulders, hips and legs. Roll the patient in unison, keeping the head and spine in alignment until resting on their side. Position the backboard. Log roll the patient onto the backboard. STEP 4: Secure the patient\u2019s body. Secure the patient\u2019s chest. Secure the arms, hips, thighs and legs with remaining straps. If needed, secure the patient\u2019s hands in front of the body. STEP 5: Secure the patient\u2019s head. Place padding beneath the head if not aligned with the body. If no commercial immobilizer is available, use a folded or rolled blanket around the head and neck. Secure the forehead."
    },
    {
        "Introduction": "As an emergency medical responder (EMR), you will encounter many types of musculoskeletal injuries, including fractures, dislocations, sprains, strains, head injuries, spinal cord injuries, and chest injuries. You need to understand the basic anatomy and functioning of the musculoskeletal system and study the causes, or mechanisms, of injury. This will allow you to better understand the various injuries and know what care is needed. Before you can treat musculoskeletal injuries, you must be able to recognize their signs and symptoms and to differentiate between open and closed injuries. Providing proper care at the scene can prevent additional injury or disability. This chapter describes how to manage injuries to the upper and lower extremities, the head, the spinal cord, and the chest. It also provides information on standard precautions and what steps you need to take to protect yourself when caring for a patient with musculoskeletal injuries.",
        "Patient Assessment of Injuries to Muscles and Bones": "When assessing a patient who has sustained an injury to the muscles and bones, you need to complete all five of the parts of the patient assessment sequence. Begin with a thorough overview of the scene. This can often give you valuable information about the intensity and force of the incident. Do not get tunnel vision because the patient has an obvious injury. You need to complete all parts of the scene size-up to render the scene safe and to gain as much information as you can about the mechanism of injury. Be especially careful about following standard precautions to protect you and the patient from infectious diseases. When a patient has sustained a traumatic injury, there is a high chance that blood will be present.\n\nPerform a complete primary assessment to determine whether the patient has any life-threatening conditions related to his or her airway, breathing, or circulation (including serious blood loss). Sometimes when a patient has an obvious soft-tissue injury or deformity of a limb, he or she may focus on that single injury and not be aware of additional conditions. These additional conditions may be more serious than the presenting problem (the chief complaint).\n\nWhen performing a patient assessment on a trauma patient, it is often more efficient and helpful to perform the primary assessment and then immediately follow with the secondary assessment, holding off on obtaining the patient\u2019s medical history. Reordering the steps in this manner will give you a complete picture of all the physical findings about the patient. While you perform the secondary assessment, be thorough and systematic in examining all parts of the patient. However, do not get tunnel vision and assume that a trauma patient has no medical conditions. Heart conditions and low blood glucose levels in patients with diabetes can result in traumatic events. Be sure to perform a thorough SAMPLE medical history to determine whether the patient has any medical conditions that require attention. Finally, continue to reassess the patient every 15 minutes if the patient\u2019s condition is stable and every 5 minutes if the condition is unstable until other medical providers take over the care of the patient.",
        "The Anatomy and Function of the Musculoskeletal System": "The musculoskeletal system has two parts: the skeletal system, which provides support and form for the body, and the muscular system, which provides both support and movement.",
        "The Skeletal System": "The skeletal system consists of 206 bones and is the supporting framework for the body. The four functions of the skeletal system are:\n1. To support the body\n2. To protect vital structures\n3. To assist in body movement\n4. To manufacture red blood cells\nThe skeletal system is divided into seven areas:\n1. Head, skull, and face\n2. Spinal column\n3. Shoulder girdle\n4. Upper extremities\n5. Rib cage (thorax)\n6. Pelvis\n7. Lower extremities\n\nThe bones of the head include the skull and the lower jawbone. The skull consists of many bones fused together to form a hollow sphere. It contains and protects the brain. The jawbone is a movable bone attached to the skull that completes the structure of the face.\n\nThe spine consists of a series of separate bones called vertebrae. The spinal vertebrae are stacked on top of each other. Muscles, tendons, disks, and ligaments hold them together. The spinal cord, a group of nerves that carry messages to and from the brain, passes through a hole in the center of each vertebra. In addition to protecting the spinal cord, the spine is the primary support structure for the entire body.\n\nThe spine has five sections. The five sections of the spine are:\n1. Cervical spine (neck)\n2. Thoracic spine (upper back)\n3. Lumbar spine (lower back)\n4. Sacrum\n5. Coccyx (tailbone)\n\nThe shoulder girdles form the third area of the skeletal system. Each shoulder girdle supports an arm and consists of the collarbone (clavicle) and the shoulder blade (scapula).\n\nThe fourth area of the skeletal system, the upper extremities, consists of three major bones as well as the wrist and hand. The arm has one bone (the humerus), and the forearm has two bones (the radius and the ulna). The radius is located on the thumb side of the arm; the ulna is located on the side of the little finger. There are several bones in the wrist and hand. However, you do not need to learn their names at this time and you can consider them as one unit for the purposes of emergency treatment.\n\nThe fifth area of the skeletal system is the rib cage or chest (thorax). The 12 sets of ribs protect the heart, lungs, liver, and spleen. All of the ribs are attached to the spine. The upper five rib sets connect directly to the sternum (breastbone). A bridge of cartilage connects the ends of the 6th through 10th rib sets to each other and to the sternum. The 11th and 12th rib sets are called floating ribs because they are not attached to the sternum. The sternum is located in the front of the chest. The pointed structure at the bottom of the sternum is called the xiphoid process.\n\nThe sixth area of the skeletal system is the pelvis. The pelvis links the body and the lower extremities. The pelvis also protects the reproductive organs and the other organs located in the lower abdominal cavity.\n\nThe lower extremities (the thigh and the leg). The thighbone (femur) is the longest and strongest bone in the entire body. The leg consists of two major bones, the tibia and fibula, as well as the ankle and foot. The kneecap (patella) is a small, relatively flat bone that protects the front of the knee joint. Like the wrist and hand, the ankle and foot contain a large number of smaller bones that can be considered as one unit.\n\nA protective bony structure surrounds each of the body\u2019s essential organs. The skull protects the brain. The vertebrae protect the spinal cord. The ribs protect the heart and lungs. The pelvis protects the lower abdominal and reproductive organs. A vital but often overlooked function of the skeletal system is to produce red blood cells. Red blood cells are manufactured primarily within the spaces inside the bone called the marrow.",
        "The Muscular System": "The muscles of the body provide both support and movement. Muscles are attached to bones by tendons and cause movement by alternately contracting (shortening) and relaxing (lengthening). Muscles are usually paired in opposition: As one member of the pair contracts, the other relaxes. This mechanical opposition moves bones and enables you to open and close your hand, turn your head, and bend and straighten your knee or other joints. To straighten the elbow, for example, the biceps muscle relaxes and an opposing muscle on the back of the arm contracts.\n\nThe musculoskeletal system gets its name from the coordination between the muscular system and the skeletal system to produce movement. Movement occurs at joints, where two bones come together. Ligaments hold the bones together. Ligaments are thick bands that arise from one bone, span the joint, and insert into the adjacent bone.\n\nThe body has three types of muscles: voluntary, involuntary, and cardiac. Voluntary, or skeletal, muscles are attached to bones and can be contracted and relaxed by a person at will. They are responsible for the movement of the body. Involuntary, or smooth, muscles are found on the inside of the digestive tract and other internal organs of the body. They are not under conscious control and perform their functions automatically. Cardiac muscle is found only in the heart. Most musculoskeletal injuries involve skeletal muscles.",
        "Mechanism of Injury": "As an EMR, you must understand the mechanism of injury (MOI), or how injuries occur. Three types of mechanisms of injury cause musculoskeletal injuries: direct force, indirect force, and twisting force. Examples of each mechanism and the type of injury it causes are as follows: Direct force. A car strikes a pedestrian on the leg. The pedestrian sustains a broken leg. Indirect force. A woman falls on her shoulder. The force of the fall transmits energy to the middle of the collarbone and the excess force breaks the bone. Twisting force. A football player is tackled as he is turning. As the leg twists, the knee sustains a severe injury. Injuries can be caused by direct force at the site of impact or by indirect force at an impact site removed from the site of the injury.\n\nAs an EMR, you will see many different types of traumatic injuries. Some of these injuries will be the result of motor vehicle crashes involving one or more motor vehicles or a motor vehicle and a pedestrian; others will be the result of athletic activities, work-related accidents, falls, or violence. You will see injuries in people of all ages\u2014from very young children to older people. Use the information provided by your dispatcher and gathered from your overview of the scene to identify the possible mechanisms of injury. You will gain additional information from examining and questioning the patient. By understanding the mechanism of injury (how the injury occurred), you will be better able to assess the patient and provide the needed treatment.",
        "A Word About Terminology": "A patient\u2019s injuries can be described in different ways. You must rely on your senses of sight and touch to determine the type of injury the patient has experienced. You must also listen to the information that the patient gives you. However, keep in mind that, as an EMR, you do not have the training or tools to diagnose an injury as a physician can. The next section defines fractures, dislocations, and sprains/strains. Although you are not expected to diagnose these injuries, the patient\u2019s signs and symptoms will lead you to suspect that a certain injury is most probable. Some instructors and medical directors may choose to identify musculoskeletal injuries strictly in terms of the signs and symptoms present, such as a painful, swollen, deformed extremity. Others may choose to use terms such as suspected or possible fracture, dislocation, or sprain. Regardless of the terminology used, the most important part of your job is to provide the best assessment and treatment for the patient.",
        "Types of Injuries": "It is often difficult to distinguish one type of musculoskeletal extremity injury from another. All three types are serious, and all extremity injuries must be identified so that appropriate medical treatment can be provided.",
        "Fractures": "A fracture is a broken bone. A variety of mechanisms can cause a fracture, but a fracture most often occurs as a result of a significant force, unless the bone is weakened by a disease such as osteoporosis or cancer. Fractures are generally classified as closed or open In the more common closed fracture, the bone is broken but there is no break in the skin. In an open fracture, the bone is broken and the overlying skin is lacerated. The open wound can be caused by a penetrating object, such as a bullet, or by the fractured bone end itself protruding through the skin. Open fractures are likely contaminated by dirt and bacteria that may lead to infection. A patient with an open fracture requires more extensive care in the hospital to ensure that the associated wound is properly cleaned and the fracture properly treated to reduce the chance of developing a serious infection. Both open and closed fractures injure adjacent soft tissues, resulting in bleeding at the fracture site. Fractures can also injure nearby nerves and blood vessels, causing severe nerve injury and excessive internal or external bleeding.",
        "Dislocations": "A dislocation is a disruption that tears the supporting ligaments of the joint. The bone ends that make up the joint separate completely from each other and can lock in one position. Any attempt to move a dislocated joint is very painful. Because many nerves and blood vessels lie near joints, a dislocation can damage these structures as well.",
        "Words of Wisdom": "Three major types of musculoskeletal injuries:\n1. Fractures\n2. Dislocations\n3. Sprains and strains",
        "Sprains and Strains": "A sprain is a joint injury caused by excessive stretching of the supporting ligaments. Think of it as a partial dislocation. Strains are caused by stretching or tearing of a muscle.",
        "Signs and Symptoms of extremity injuries": "Signs and symptoms of extremity injuries include the following:\nPain at the injury site\nAn open wound\nSwelling and discoloration (bruising)\nThe patient\u2019s inability or unwillingness to move the extremity\nDeformity or angulation\nTenderness at the injury site",
        "Standard Precautions and Musculoskeletal Injuries": "While you examine and treat patients with musculoskeletal injuries, you need to practice standard precautions. These patients may have open wounds related to the musculoskeletal injury or to a separate, open soft-tissue injury. Assume that trauma patients have open wounds that pose a threat of infection. Always wear approved gloves. When you are responding to motor vehicle crashes or to other situations that may present a hazard from broken glass or other sharp objects, it is wise to wear heavy rescue gloves that provide protection from sharp objects. Some EMRs wear latex or nitrile gloves under the heavy rescue gloves for added protection from infectious body fluids. If the patient has active bleeding that may splatter, wear protection for your eyes, nose, and mouth as well.",
        "Safety": "Standard precautions are for your protection.",
        "Examination of Musculoskeletal Injuries": "The three essential steps in examining a patient with a limb injury are as follows: 1. General assessment of the patient according to the patient assessment sequence. 2. Examination of the injured part 3. Evaluation of the circulation, sensation, and movement in the injured limb",
        "General Patient Assessment": "When caring for an injured patient, you must carry out all the steps in the patient assessment process before focusing your attention on any injured limb. Once you have checked and stabilized the patient\u2019s airway, breathing, and circulation (ABCs), you can then direct your attention to the injured limb identified during the physical examination. Limb injuries are not life threatening unless there is excessive bleeding from an open wound. Therefore, it is essential that you first stabilize the patient\u2019s airway, breathing, and circulation (ABCs) before you focus on a limb injury, regardless of the pain or deformity that may be present at that injury site. As you examine and treat patients with musculoskeletal injuries, remember that this is a frightening and painful experience for them. Explain what you are doing as you conduct your examination and stabilize the patient. Treat the patient with the same care and consideration that you would give to a close member of your own family.",
        "Examination of the Injured Limb": "As an EMR, you should initially inspect the injured limb and compare it to the opposite, uninjured limb. To do this, gently and carefully cut away any clothing covering the wound, if necessary. (Never hesitate to cut a patient\u2019s clothing to uncover a suspected injury.) When you examine the limb, you may find any one of the following: An open wound Deformity Swelling Bruising After you uncover and look at the injured limb, gently feel it for any points of tenderness. Tenderness is the best indicator of an underlying fracture, dislocation, or sprain.\n\nTo detect limb injury, start at the top of each limb (where it connects to the body) and using both hands, squeeze the entire limb in a systematic, firm (yet gentle) manner, moving down the limb and away from the body Make sure you examine the entire extremity.\n\nAs you carry out your hands-on examination, it is important to ask the patient where it hurts most; the location of greatest pain is probably the injury site. Also ask if the patient feels tingling or numbness in the extremity because this may indicate nerve damage or lack of circulation. Careful inspection and a gentle hands-on examination will identify most musculoskeletal injuries. After you have made a careful visual and hands-on examination, and if the patient shows no sign of injury, ask the patient to move the limb carefully. If there is an injury, the patient will report pain and refuse to move the limb.\n\nThe signs or symptoms described earlier (deformity, swelling, bruising, tenderness, or pain with motion) indicate the presence of a limb injury. Only one sign is necessary to indicate an injury to the limb. Manage all limb injuries, regardless of type or severity, in the same way.",
        "Treatment_1": "If even the slightest motion causes the patient to report pain, NO further motion should be attempted.",
        "Evaluation of Circulation, Sensation, and Movement": "Once you suspect limb injury, you must evaluate the circulation and sensation in that limb. Many important blood vessels and nerves lie close to the bones, especially around major joints. Therefore, any injury may have associated blood vessel or nerve damage. It is also essential to check circulation and sensation after any movement of the limb (such as for splinting). Moving the limb during splinting may cause a bone fragment to press against or even cut a blood vessel or nerve.",
        "Skill Drill 15-1": "1. Pulse. Feel the pulse distal to the point of injury. If the patient has an upper extremity injury, check the radial (wrist) pulse Step 1. If the patient has a lower extremity injury, check the tibial (posterior ankle) pulse Step 2.\n2. Capillary refill. Test the capillary refill in a finger or toe of any injured limb. Firm pressure on the tip of the nail causes the nail bed to turn white Step 3. Release the pressure and the normal pink color should return by the time it takes to say \"capillary refill\" Step 4. If the pink color does not return in this 2-second interval, it is considered to be delayed or absent and indicates a circulation condition in the limb. A cold environment will naturally delay capillary refill, so in that situation, do not use capillary refill to assess an injured limb. The absence of a pulse or capillary refill indicates that a limb is in immediate danger. Impaired circulation demands prompt transportation and prompt medical treatment at an appropriate medical facility.\n3. Sensation. The patient\u2019s ability to feel your light touch on the fingers or toes is a good indication that the nerve supply is intact. In the hand, check sensation by lightly touching the tips of the index and little fingers Step 5. In the foot, check the tip of the big toe and the top of the foot for sensation Step 6.\n4. Movement. If the hand or foot is injured, do not have the patient perform this part of the test. When the injury is between the hand and the body or the foot and the body, have the patient open and close the fist Step 7 or flex the foot of the injured limb Step 8. These simple movements indicate that the nerves to these muscles are working. Sometimes any attempt at motion will produce pain. In this situation, do not ask the patient to move the limb any further. Consider any open wound, deformity, swelling, or bruising of a limb evidence of a possible limb injury and treat it as such. Try to keep the extremity in a position of comfort for the patient.",
        "Treatment of Musculoskeletal Injuries": "Regardless of their extent or severity, treat all limb injuries in the same way in the field. For all open extremity wounds, first cover the entire wound with a dry, sterile dressing, and then apply firm but gentle pressure to control bleeding, if necessary. The sterile compression dressing protects the wound and underlying tissues from further contamination. Apply a cold pack to painful, swollen, or deformed extremities. Then splint the injured limb.",
        "General Principles of Splinting": "Splint all limb injuries before moving a patient, unless the environment prevents effective splinting or threatens the patient\u2019s life (or your life). Splinting prevents the movement of broken bone ends, a dislocated joint, or damaged soft tissues and thereby reduces pain. With less pain, the patient relaxes and the trip to the medical facility is easier. Splinting also helps to control bleeding and decreases the risk of damage to the nearby nerves and vessels by sharp bone fragments. Splinting prevents closed fractures from becoming open fractures during movement or transportation.\nAll EMRs should know the following general principles of splinting:\n1. In most situations, remove clothing from the injured limb to inspect the limb for open wounds, deformity, swelling, bruising, and capillary refill.\n2. Note and record the pulse, capillary refill, sensation, and movement distal to the point of injury, both before and after splinting.\n3. Cover all open wounds with a dry, sterile dressing before applying the splint.\n4. Do not move the patient before splinting, unless there is an immediate danger to the patient or to you.\n5. Immobilize the joint above and the joint below the injury site.\n6. Pad all rigid splints.\n7. When applying the splint, use your hands to support the injury site and minimize movement of the limb until splinting is completed.\n8. Splint the limb without moving it unnecessarily.\n9. When in doubt, splint.",
        "Materials Used for Splinting": "Many different materials can be used as splints, if necessary. Even when standard splints are not available, you can bind an injured arm to a patient\u2019s chest and secure an injured leg to the other, uninjured lower extremity for temporary stability.",
        "Rigid splints": "are made from firm material and are applied to the sides, front, or back of an injured extremity. Common types of rigid splints include padded board splints, molded plastic or aluminum splints, padded wire ladder splints, structured aluminum malleable (SAM) splints, and folded cardboard splints. Padded wire ladder or SAM splints can be molded to the shape of the limb to splint it in the position found.",
        "Treatment_0": "Three basic types of splints are as follows: Rigid, Soft, Traction",
        "Soft Splints": "Soft splints are flexible and easy to place around an injured limb. The most commonly used soft splints are vacuum splints and inflatable, clear plastic air splints. Vacuum splints become rigid when air is removed from the splint. Air splints become rigid when they are inflated with air. Vacuum splints consist of an airtight covering that is shaped to fit around an arm or a leg. They are constructed with an inner layer of airtight fabric and an outer layer of the same fabric. Located between these two layers of fabric are small beads of a hard foam material surrounded by air. This makes the splint flexible and easy to mold to the contours of the patient\u2019s injured limb. When you remove air from inside the vacuum splint, it becomes more rigid and provides support for the injured limb. A vacuum pump to remove the air is included with the splint. Most vacuum splints have Velcro fasteners to make it easier to apply the splint. Vacuum splints are not transparent so it is not possible to observe the limb once the splint is applied. Protect vacuum splints from damage from sharp objects. If they are punctured, the splint will become flexible and no longer be an effective splint. When using vacuum splints, you must monitor the pulse, movement, and sensation of the injured limb and the status of the vacuum splint itself. Changes in altitude and temperature can affect the rigidity of a vacuum splint. The steps for applying a vacuum splint are illustrated in Skill Drill 15-2. \n1. Assess distal pulse and motor and sensory function. \n2.Your partner supports and stabilizes the injured limb, applying traction if needed. \n3. Gently place the injured limb onto the vacuum splint, and wrap the splint around the limb.\n4. Draw the air out of the splint through the suction valve and then seal the valve. Once the valve is sealed, the vacuum splint becomes rigid, conforming to the shape of the deformed limb and stabilizing it. \n5. Check distal circulation and nervous functions, and monitor them en route.\n\nAir splints are constructed of a clear, flexible, plastic material. They are manufactured in a variety of sizes and shapes, with or without a zipper that runs the length of the splint\n\nAir splints are applied around the limb and then inflated by blowing into a specially constructed valve. Do not use a pump to inflate an air splint. The pressure from the air forms the air splint around the injured limb in a manner opposite from the way a vacuum splint works. Air splints are largely transparent, so it is possible to monitor the appearance of the injured limb after you apply one. Air splints provide support and are comfortable for the patient. Because they provide uniform pressure, you can use an air splint to apply pressure on a bleeding wound.\n\nProtect air splints from sharp objects that could puncture them. When using air splints, monitor the pulse, motor function, and sensation of the injured limb. Also monitor the level of inflation of the air splint. Changes in altitude and temperature can affect the rigidity of an air splint.",
        "Safety_1": "NEVER use anything but the air from your mouth to inflate air splints!",
        "Traction Splints": "A traction splint holds a lower extremity fracture in alignment by applying a constant, steady pull on the extremity. Properly applying a traction splint requires two well-trained emergency medical technicians (EMTs) working together; one person cannot do it alone. While most EMRs do not learn the skills necessary to apply this type of splint, you may be asked to assist trained medical personnel in the placement of a traction splint, and you should be familiar with the general techniques, as shown later in Skill Drill 15-6. There are several different types of traction splints. If you will be helping to apply a traction splint, you need instruction on the device used by your service.",
        "Treatment_2": "Improvised splints can be made from rolled newspapers, magazines, towels, or belts",
        "Splinting Specific Injury Sites": "A person with EMR training and with materials readily available can carry out the treatment techniques described here. Most splinting techniques are two-person operations. One person stabilizes and supports the injured limb while the other person applies the splint.",
        "Shoulder Girdle Injuries": "The easiest way to splint most shoulder injuries is to apply a sling made of a triangular bandage and to secure the sling (and arm) to the patient\u2019s body with swathes around the arm and chest. Apply the sling by tying a knot in the point of the triangular bandage, placing the elbow into the cup formed by the knot, and passing the two ends of the bandage up and around the patient\u2019s neck. Tie the sling so the wrist is slightly higher than the elbow.\n\nTo keep the arm immobilized, fold another triangular bandage until you have a long swathe that is 3 to 4 inches (8 to 10 cm) wide.\n\nTie one or two swathes around the upper arm and chest of the patient. This easily applied splint adequately immobilizes fractures of the collarbone, most shoulder injuries, and fractures of the arm.",
        "Shoulder Dislocation": "The dislocated shoulder is the only shoulder girdle injury that is difficult to immobilize with a sling and swathe. In a shoulder dislocation, there is often a space between the upper arm and the chest wall. Fill this space with a pillow or a rolled blanket before applying a sling and swathe as for other shoulder injuries.",
        "Words of Wisdom_3": "When triangular bandages are not available, loop a length of gauze (or even a belt) around the patient\u2019s wrist and suspend the limb from the neck. Secure the arm gently, but firmly, to the chest wall with another length of gauze or belt. If you have not cut away the coat a patient is wearing, you can also pin a coat sleeve to the front of the patient\u2019s coat as a temporary splint. This technique is less secure than a sling and swathe, but it may be of use in cold weather areas.",
        "Elbow Injuries": "Do not move an injured elbow from the position in which you find it. You must splint the elbow as it lies because any movement can cause nerve or blood vessel damage. If the elbow is straight, splint it straight. If the elbow is bent at an unusual angle, splint it in that position.\n\nAfter splinting the injured elbow of a patient who does not have a significant shoulder injury (and only if it does not cause pain), gently move the splinted injury to the patient\u2019s side for comfort and ease of transport. An effective splint for an injured elbow is a pillow splint. Wrap the elbow in a pillow, add additional padding to keep the elbow in the position found, and secure the pillow as shown in.\n\nThe patient is usually transported in a sitting position with the splinted elbow resting on his or her lap. A padded wire ladder or SAM splint is also effective for splinting elbows that are found in severely deformed positions.",
        "Forearm Injuries": "Several splints can be used to stabilize the forearm: the air splint, the cardboard splint, the SAM splint, and even rolled newspapers and magazines. Be sure to pad all rigid splints adequately. \n1. Support and stabilize the injured limb. \n2. Form the SAM splint to the injured forearm \n3. Place the splint under the injured limb Step 2. \n4. Secure the splint in place with gauze Step 3. \n5.Recheck the pulse, capillary refill, and sensation of the injured forearm.\n\nAn air splint can be applied quickly, and it immobilizes the forearm quite well. Of the several types of air splints available, the one with a full-length zipper is easiest to use Skill Drill 15-4 \n\n1. Apply gentle traction to the limb and support the site of injury. Have your partner place the open, deflated splint around the limb. 2. Zip up the splint and inflate it by mouth. Then test the pressure in the splint. With proper inflation, you should just be able to compress the walls of the splint together with a firm pinch between the thumb and index finger near the edge of the splint. 3. Check and record pulse and motor and sensory functions, and monitor them periodically until the patient reaches the hospital.",
        "Skill Drill 15-5: Applying an Unzippered Air Splint": "\n1. Assess distal pulse and motor and sensory functions. \n2. Your partner supports the injured limb. Place your arm through the splint to grasp the patient\u2019s hand or foot. \n3. Place your arm through the splint. Extend your hand beyond the splint, and grasp the hand or foot of the injured limb Step 1.\n4. Apply gentle traction to the hand or foot while sliding the splint onto theinjured limb. The hand or foot of the injured limb should always be included in the splint Step 2\n5. Your partner inflates the splint by mouth Step 3.\n6. Test the pressure in the splint. You must do this with either type of air splint.\n7. Check and record pulse and motor and sensory functions, and monitor them en route.",
        "Hand, Wrist, and Finger Injuries": "As an EMR, you will see a variety of hand injuries, all of which can be potentially serious. The functions of the fingers and hand are so complex that any injury, if poorly or inadequately treated, may result in permanent deformity and disability. Treat even seemingly simple lacerations carefully. You can use a bulky hand dressing and a short splint to immobilize all injuries of the wrist, hand, and fingers. Send any amputated parts to the hospital with the patient by placing them in a sealed plastic bag. Cool the plastic bag by placing it in a cold water bath; never place the amputated part directly on ice.\n\nTo treat injuries of the hand, wrist, or fingers, first cover all wounds with a dry, sterile dressing. Then place the injured hand and wrist into the position of function. Place one or two soft roller dressings into the palm of the patient\u2019s hand. Apply a splint to hold the wrist, hand, and fingers in the position of function and secure the splint with a soft roller bandage.",
        "Treatment_8": "If you have to improvise a splint for a forearm injury, shows how to apply a splint made of magazines and newspapers.",
        "Applying an improvised splint using magazines": "A. Immobilize the fracture above and below the fracture site. B. Place improvised splinting material around injured extremity. C. Secure in place with gauze, cravats, or other available material.",
        "Pelvic Fractures": "Fractures of the pelvis often involve severe blood loss because the broken bones can easily lacerate the large blood vessels that run directly beside the pelvis. These vessels can release a large amount of blood into the pelvic area. Pelvic fractures commonly cause shock. Therefore, you must always treat the patient for shock. The most definite sign of a pelvic fracture is tenderness when you use both your hands to firmly compress the patient\u2019s pelvis. Immobilize fractures of the pelvis with a long backboard. EMTs may apply a pelvic compression binder or a pneumatic antishock garment to stabilize the fracture and treat shock.",
        "Examining the patient for pelvic fracture.": "Push down. Push in.",
        "Hip Injuries": "Two types of hip injuries are common: dislocations and fractures. Both injuries may result from high-energy trauma. When a passenger in the front seat of a motor vehicle is not wearing a seat belt and the vehicle crashes, the person is thrown forward and crashes against the dashboard. The impact of the knee against the dashboard is transmitted up the shaft of the thighbone (femur), injuring the hip and often producing either a dislocation or a fracture, or both.\n\n Hip fractures actually occur at the upper end of the femur, rather than in the hip joint itself. High-energy trauma is not the only cause of hip fractures. They Can occur in older adults, especially women, after only minimal trauma (such as falling down). These fractures in older adults occur because bone weakens and becomes more fragile with advancing age, a condition called osteoporosis. Patients with osteoporosis may sustain major fractures from minor falls.\n\nA dislocated hip is extremely painful, especially when any movement is attempted. The joint is usually locked with the thigh flexed and rotated inward across the midline of the body. The knee joint is often flexed as well. Fractures of the hip region usually cause the injured limb to become shortened and externally (outwardly) rotated.\n\nTreat all hip injuries by immobilizing the hip in the position found. Use several pillows and/or rolled blankets, especially under the flexed knee. The patient should be placed on a backboard for transportation. The patient and the limb should be well stabilized to eliminate all motion in the hip region.\n\nBecause fractures of the upper end of the femur are so common in older patients. Any older person who has fallen and reports pain in the hip, thigh, or knee\u2014even if there is no deformity\u2014should be splinted and transported to the hospital for radiographic evaluation.",
        "Skill Drill 15-6: Applying a Traction Splint": "Step 1 Place the splint beside the uninjured limb, adjust the splint to the proper length, and prepare the straps. Step 2: Support the injured limb while your partner fastens the ankle hitch about the foot and ankle. Step 3 Continue to support the limb while your partner applies gentle traction to the ankle hitch and foot. Step 4 Continue to support the limb while your partner applies gentle traction to the ankle hitch and foot. Step 5 Pad the groin and fasten the strap around the midthigh. Step 6. Connect the loops of the ankle hitch to the end of the splint while your partner continues to maintain traction. Fasten the support straps to hold the limb securely in the splint.",
        "Straightening an injured leg for splinting.": "A. The first rescuer grasps the injured leg at the knee and applies traction in the long axis of the body. B. The second rescuer grasps the ankle. C. The second rescuer straightens the leg. D. The second rescuer maintains traction by leaning back.",
        "Thigh Injuries": "Trauma to the thigh can bruise the muscles or fracture the shaft of the femur. A fractured femur is very unstable and usually produces significant thigh deformity, with much bleeding and swelling. The treatment of femoral fractures requires skill and proper equipment. As an EMR, you can treat for shock and help prevent further injury. Place the patient in as comfortable a position as possible, treat for shock, and call for additional personnel and equipment. However, there are times, such as after a motor vehicle crash, when you may have to move the patient quickly before proper equipment and additional personnel arrive. Learn and practice emergency temporary splinting for lower extremity injuries. Secure both legs together with several swathes, cravats, or bandages to immobilize the two lower extremities as one unit. This technique allows you to remove the patient from a dangerous environment quickly. A traction splint is the most effective way to splint a unilateral fractured femur. Traction splints are designed specifically for this purpose. Although you most likely do not have a traction splint in your EMR life support kit, you should learn this technique and know how it works in general, so that you can assist other EMS personnel, as needed. Before applying a traction splint, trained EMTs align deformed fractures by applying manual longitudinal traction. Once manual traction is applied, it must be maintained until the traction splint is fully in place. Because many different types of traction splints are available, you should learn to use the one that your department uses. Most are applied using basically the same method. \n\nSkill Drill 15-6 illustrates the steps for applying a Hare traction splint: 1.Place the splint beside the patient\u2019s uninjured leg and adjust it to the proper length. Open and adjust the four support straps. Position the support straps at the midthigh, above the knee, below the knee, and above the ankle. 2. The first rescuer supports and stabilizes the injured limb while the second rescuer fastens the ankle hitch about the patient\u2019s ankle and foot. 3. The first rescuer supports the leg at the site of the suspected injury while the second rescuer manually applies gentle traction to the ankle hitch and foot. Use only enough force to reposition the limb so it will fit into the splint. The first rescuer slides the splint into position under the patient\u2019s injured limb. 3. Pad the groin area and gently apply the strap around the midthigh. 4. The first rescuer connects the loops of the ankle hitch to the end of the splint while the second rescuer continues to maintain traction. Apply gentle traction to the connecting strap between the ankle hitch and the splint, just strongly enough to maintain limb alignment. 5. Once the proper traction is applied, fasten the support straps to hold the limb securely in the splint. Check all support straps to make sure they are secure.\n\n To apply proper traction using this type of splint, it is essential that the foot end of the traction splint be elevated 6 to 8 inches (15 to 20 cm) off the ground. If the heel of the injured leg touches the ground, you will lose traction and have to reapply it. Most traction splints include a foot stand that elevates the limb. Check and recheck the pulse, capillary refill, and nerve function before and after a splint is applied. If your department uses a different type of traction splint, you will need to be instructed in how to apply it properly.",
        "Knee Injuries": "Always immobilize an injured knee in the same position that you find it. If it is straight, use long, padded board splints or a long-leg air splint. If there is a significant deformity, place pillows, blankets, or clothing beneath the knee, secure the splint materials to the leg with bandages, swathes, or cravats, and secure the injured leg to the uninjured leg. Then place the patient on a backboard.",
        "Leg Injuries": "Like fractures of the forearm, fractures of the leg can be splinted with air splints, cardboard splints, and even magazines and newspapers. It takes two trained people to splint an injured leg. One person supports the leg with both hands (above and below the injury site), while the other person applies the splint.\n\n1. The first rescuer supports the injured limb.\n2. The second rescuer slides the splint under the limb Step 1.\n3. The second rescuer places the splint around the limb Step 2.\n4. The first rescuer slides his or her hands out of the splint while the second rescuer inflates the splint Step 3. 5.Either rescuer rechecks the pulse, capillary refill, and sensation of the injured leg.",
        "Ankle and Foot Injuries": "You can splint fractures of the ankle and foot with a pillow or an air splint. Place the pillow splint around the injured ankle and foot, and tie or pin it in place Skill Drill 15-8: 1. Place a pillow under the injured limb Step 1. 2. Mold the pillow around the foot and ankle. 3. Secure the pillow with cravats, swathes, or bandages Step 2. 4. Recheck the pulse, capillary refill, and sensation Step 3",
        "Additional Considerations": "Remember that extremity injuries are not, in themselves, life threatening unless excessive bleeding is present. You may not always have the equipment or help you need to manage all types of extremity injuries. You may not even have time to splint an injury before additional EMS personnel arrive. There will be times, however, when you are the only trained person at the scene of an incident. To prepare for such situations, practice splinting until you can quickly and competently apply the principles in any situation. Because you may find patients in a variety of positions and locations, practice splinting both a sitting and a prone volunteer.\n\nIt takes two people to splint most limb injuries adequately: one person to stabilize and support the extremity and one person to apply the splint. Most of the principles and techniques of splinting covered in this chapter require that you work with another member of the EMS team. Learn how the team functions as a unit during stressful situations and be prepared to work with any member of the EMS team who arrives to assist you.",
        "Treatment_16": "Pad all rigid splints to provide the best stabilization and pain relief. Do not apply any splint too tightly. Recheck the pulse, capillary refill, and",
        "Voices of Experience": "A fancy splint, especially if it required manipulating the injured extremity, was not necessary.\"\n\nEarly in my career, when faced with a patient who had a painful, bruised, or swollen injury, I would complete a full primary and secondary assessment. Upon completion of my assessment, and after realizing that the patient had only an isolated musculoskeletal injury, I would put my splinting and immobilizing knowledge and skills to use.\n\nMany times we would splint extremities with padded boards or padded metal splints, then tape or use cravats to secure the splint to the extremity to prevent continued movement and pain.\n\nLooking back, I believe many times we manipulated the injury more than necessary by applying the splint at the scene and then removing it at the emergency department. In many cases, we caused more movement and pain than if we had used simple splinting material or had the patient self-splint their injury. When delivering the patient to the hospital after completing a detailed splint, we would often get funny looks from the hospital staff as they were removing our splint. Over the years, I have realized that a fancy splint, especially if it required manipulating the injured extremity, was not necessary. On one occasion, we moved a patient with a chief complaint of hip pain from her couch onto a scoop stretcher. We then secured her to a backboard, making sure we did not move her excessively. We then put her on the ambulance cot and transported her to the hospital, which was a 45-minute transport. Really! With the experience I have now gained I would do a three-person lift, placing her directly on the soft ambulance cot with blankets and pillows under her knees and her head raised for comfort. I would also call for an advanced life support intercept if the patient needed medications for pain. Not only can you immobilize the hip on the stretcher with pillows and straps, but you can avoid making your patient lie on a hard, flat backboard where bed sores can start forming within 20 minutes. You\u2019ve probably heard the phrase \u201cKeep it simple.\u201d many times, and in EMS, this holds true most of the time Use simple equipment that minimizes movement and pain and that can be applied and removed easily. Vacuum splints make splinting very easy. Don\u2019t forget to put a cold compress and a gauze or towel on the injury to decrease swelling. Keep it simple, and have a great career in EMS.",
        "Injuries of the Head (Skull and Brain)": "Severe head and spinal cord injuries can result from many different kinds of trauma. These injuries are common causes of death and can lead to irreversible paralysis and permanent brain damage. Improperly handling a patient after an incident can cause further injury or death. For example, well-intentioned citizens pulling a patient from a wrecked car or poor treatment from inadequately trained emergency personnel can cause spinal injuries. As an EMR, you must know what to do to provide prompt treatment and avoid errors that may make the injury worse.\n\nThe human skull has two primary parts: 1. The cranium, a tough four-bone shell that protects the brain. 2. The facial bones, which give form to the face and furnish frontal protection for the brain.",
        "Mechanisms of Injury": "Head injuries are common with certain types of trauma. Of patients involved in motor vehicle crashes, 70% sustain some degree of head injury. Imagine the cranium as a rigid bowl, containing the delicate brain. Between the skull and brain, a fluid called cerebrospinal fluid (CSF) cushions the brain from direct blows. A direct force such as a hammer blow can injure the skull and the brain inside. Indirect forces can also cause injury, such as in a motor vehicle crash when the head strikes the windshield and causes the brain to bounce against the inside of the skull.\n\nSpinal injury is often associated with head injury. The force of direct blows to the head is often transmitted to the spine, producing a fracture or dislocation. The injuries may damage the spinal cord or at least put it at risk for injury. Any time you suspect or identify an injury to the head or skull, suspect injury to the neck and spinal cord as well. Therefore, immobilize the cervical spine of all patients with head injuries to protect the spinal cord",
        "Types of Head Injuries": "Injuries of the head are classified as open or closed. In a closed head injury, bleeding and swelling within the skull may increase pressure on the brain, leading to irreversible brain damage and death if it is not relieved. An open injury of the head usually bleeds profusely. Severe open head injuries are serious but not always fatal. Examine the nose, eyes, and the wound itself to see if any blood or CSF is seeping out. The CSF is clear, watery, and straw-colored. In severe cases of open head injury, brain tissue or bone may be visible",
        "Signs and Symptoms of Head Injuries": "Confusion, Unusual behavior, Unconsciousness, Nausea or vomiting, Blood from an ear, Decreasing consciousness, Unequal pupils, Paralysis, Seizures (sudden episodes of uncontrolled electrical activity in the brain), External head trauma: bleeding, bumps, and contusions",
        "Treatment of Head Injuries": "When any one sign or symptom of head injury is present, proceed as follows:\n1.\nImmobilize the head in a neutral position. Stabilize the patient\u2019s neck and prevent movement of the head. If returning the head to neutral is met with resistance, leave it in the position found.\n2.\nMaintain an open airway. Use the jaw-thrust maneuver to open the airway. Be prepared to suction if the patient vomits. Avoid movement of the head and neck.\n3.\nSupport the patient\u2019s breathing. Be sure that the patient is breathing adequately on his or her own. If not, institute mouth-to-mask or mouth-to-barrier ventilation. Administer oxygen as soon as it is available if you are trained to use it. Oxygen helps minimize swelling of the brain.\n4.\nMonitor circulation. Be prepared to support circulation by performing full cardiopulmonary resuscitation (CPR) if the patient\u2019s heart stops.\n5.\nCheck to see if CSF or blood is seeping from a wound or from the nose or ears. CSF is clear, watery, and straw colored. Do not try to stop leakage of CSF from a wound or any other opening because leakage from inside the skull relieves internal pressure.\n6.\nControl bleeding from all head wounds with dry, sterile dressings. Use enough direct pressure to control the bleeding without disturbing the underlying tissue.\n7.\nExamine and treat other serious injuries.\n8.\nArrange for prompt transport to an appropriate medical facility.",
        "Safety_18": "If a patient has a head injury, assume that an associated neck or spinal cord injury is also present. Do nothing that would cause undue movement of the head and spine. Always immobilize the entire spine before moving the patient.",
        "Words of Wisdom_19": "A concussion is a type of closed brain injury. Concussions can occur without visible signs of trauma. The signs and symptoms of a concussion can be subtle and may not be immediately apparent. Some symptoms of concussions may be immediate or they may appear hours or days after the injury. The most common symptoms of a concussion are headache, loss of memory, and confusion. Other signs and symptoms of concussion include: Temporary loss of consciousness Headache or feeling of pressure in the head Confusion or seeming to be dazed Not remembering the traumatic event Dizziness or seeing stars Nausea and vomiting Any time you see that a patient has suffered a traumatic event and exhibits these signs and symptoms, assess the patient and then prepare him or her for transport to an appropriate medical facility for evaluation by a physician.",
        "Injuries of the Face": "Facial injuries commonly result from the following types of incidents: Motor vehicle crashes in which the patient\u2019s face hits the steering wheel or windshield, Assaults, Falls. Airway obstruction is the primary danger in severe facial injuries. Severe damage to the face and facial bones can cause bleeding and the collapse of the facial bones, leading to airway conditions. If the patient has facial injuries, also suspect a spinal injury. Although facial injuries may bleed considerably, they are rarely life threatening unless the airway is obstructed.",
        "Treatment of Facial Injuries": "When facial injuries are present, proceed as follows to care for the patient: 1. Immobilize the head in a neutral position. Stabilize it to prevent further movement of the neck. 2. Maintain an open airway. Use the jaw-thrust maneuver to open the airway. Clear any blood or vomitus from the patient\u2019s mouth with your gloved fingers. 3. Support breathing. Be prepared to ventilate the patient, if necessary. 4. Monitor circulation. 5. Control bleeding by covering any wound with a dry, sterile dressing and applying direct pressure. Be sure to check for wounds inside the mouth. Try to prevent the patient from swallowing blood because this can cause vomiting. Have suction ready for use. 6. Look for and stabilize other serious injuries. 7. Arrange for prompt transport to an appropriate medical facility. If these measures do not keep the airway clear or if you are unable to control severe facial bleeding, log roll the patient onto his or her side, keeping the head and spine stable and rolling the whole body as a unit. Turn the head and body at the same time. Do not allow the neck to twist. Bandage facial injuries as described in Chapter 14, Bleeding, Shock, and Soft-Tissue Injuries. If possible, leave the patient\u2019s eyes clear of bandages so he or she can see what is happening. Being able to see reduces the patient\u2019s tendency to panic",
        "Safety_20": "If a patient has head or spine injuries, use a log roll to move the patient onto his or her side. Do not place these patients in the recovery position. Provide support for the head and neck.",
        "Injuries to the Spine": "Spinal injuries can cause irreversible paralysis. As an EMR, you must know how to handle a patient properly and provide prompt treatment. Errors may make the injury worse.",
        "Mechanisms of Injury_1": "If one or more vertebrae are injured, the spinal cord may also be injured. A displaced vertebra, swelling, or bleeding may put pressure on the spinal cord and damage it. In severe cases, the cord may be severed. If all or part of the spinal cord is cut, nerve impulses (which are like signals in a telephone cable) cannot travel to and from the brain. Without the conduction of these nerve impulses, the patient is paralyzed below the point of injury. Injury to the spinal cord high in the neck paralyzes the diaphragm and results in death. Gunshot wounds to the chest or abdomen may produce spinal cord injury at that level. Falls, motor vehicle crashes, and stabbings are other common causes of spinal injuries. Suspect a spinal injury if the patient has sustained high-energy trauma.\n\nSome common causes of spinal cord injuries are: \nAthletic collisions\nDiving injuries\nGunshot wounds and stabbings to the chest or neck\nFalls of greater than three times the patient\u2019s height\nHangings\nMotorcycle crashes at speeds of over 20 mph\nMotor vehicle crashes with the following conditions:\nPatient is ejected from vehicle\nPatient is unrestrained\nSpeed is more than 40 mph\nThere is at least 12 inches (30 cm) of intrusion into the passenger compartment",
        "Signs and Symptoms of Spinal Cord Injury": "To determine whether a patient has sustained an injury to the spinal cord, talk to the patient and perform a careful examination to help determine the mechanism of injury. Gently conduct a hands-on examination, as described in Chapter 9, Patient Assessment, to detect paralysis or weakness. Ask the patient to describe any points of tenderness or pain. Do not move the patient during your examination, and ask the patient to keep still. The key signs and symptoms of a spinal injury are noted in the following Signs and Symptoms box. During your examination, be extremely careful and take your time. Position yourself so that the patient will not need to move his or her head to communicate with you. Do not move patients unless they are in a hazardous area.",
        "Signs and Symptoms_22": "Signs and symptoms of spinal injuries include: Laceration, bruise, or other sign of injury to the head, neck, or spine Tenderness over any point on the spine or neck Pain in the neck or spine or pain radiating to an extremity Extremity weakness, numbness, paralysis, or loss of movement Loss of sensation or movement or tingling or burning sensation in any part of the body below the neck Loss of bowel or bladder control",
        "Treatment of Spinal Injuries": "If any one sign or symptom of spinal injury is present, proceed as follows: 1. Place the head and neck in a neutral position. Avoid unnecessary movement of the head. 2. Stabilize the head and prevent movement of the neck. 3. Maintain an open airway. Use the jaw-thrust maneuver to open the airway to avoid movement of the head and neck. Clear any blood or vomitus from the mouth with your gloved fingers. 4. Support the patient\u2019s breathing. A spinal cord injury may paralyze some or all of the respiratory muscles, resulting in abnormal breathing patterns. In some cases, only the diaphragm may be working. Breathing using the diaphragm only is called abdominal breathing. The abdomen (not the lungs) swells and collapses with each breath. Help the patient breathe by administering oxygen (if available) and by keeping the airway open. 5. Monitor circulation. 6. Assess the pulse, movement, and sensation in all extremities. 7. Examine and treat other serious injuries. 8. Do not move the patient unless it is necessary to perform CPR or to remove him or her from a dangerous environment. 9. Assist in immobilizing the patient using a long or short backboard. (The steps for applying long and short backboards are covered in Chapter 3, Lifting and Moving Patients.) 10. Arrange for prompt transport to an appropriate medical facility.",
        "Safety_23": "If you suspect the presence of a spinal injury, it is essential to immobilize and protect the injury until hospital tests rule out a spinal cord injury. Do not move patients unless it is necessary to perform CPR or remove them from a dangerous environment.",
        "Stabilizing the Cervical Spine": "The cervical spine is initially stabilized manually. 1. Stabilize the head and prevent movement of the neck. Place the head and neck in a neutral position. 2. In this position, the rescuer can maintain an open airway with the jaw-thrust maneuver. Do not manipulate or twist the head and neck. After you have manually stabilized the head and neck, you must maintain support until the entire spine is fully immobilized. Use a rigid collar and a long or short backboard to immobilize the cervical spine. Review the steps for applying a cervical collar and a short backboard device, which are covered in Lifting and Moving Patients.",
        "Words of Wisdom_24": "Once you have applied spinal immobilization measures, maintain them until the care of the patient is turned over to more highly trained prehospital EMS personnel or hospital-based personnel. Spinal immobilization may be removed in the hospital after a physician evaluates the patient and often after radiographs or other diagnostic tests are conducted. Some EMS systems have adopted specific protocols that permit EMTs and paramedics to remove spinal immobilization in certain specific situations after they have completed a thorough patient assessment process that follows a specific protocol approved by their medical director. The steps for evaluating a patient to determine if spinal immobilization can be removed are not taught in this course. Continue to apply spinal immobilization until you turn the care of the patient over to more highly trained EMS or hospital personnel, but be aware that they may employ a process that results in discontinuation of the immobilization procedures that you very appropriately initiated.",
        "Motorcycle and Sports Helmets": "Many patients with neck injuries are motorcyclists or sports players who are wearing protective helmets. In almost all instances, it is not necessary to remove a helmet. Helmets are frequently snug and cradle the head; therefore, they can be secured directly to the spinal immobilization device.\n\nRemove part or all of a helmet under only two circumstances: 1. When the face mask or visor interferes with adequate ventilation or with your ability to restore an adequate airway. 2. When the helmet is so loose that securing it to the spinal immobilization device will not provide adequate immobilization of the head.\n\nWhen part of a motorcycle helmet interferes with ventilation, lift the visor away from the face. In the case of a football helmet, remove the face guard. Some newer football helmets have a tough plastic strap fixing the face guard to the mask. Trainers and coaches should have a special tool readily available that can remove the face guard. Also, loosen the chin strap to facilitate the jaw-thrust maneuver. In most instances, exposing the face and jaw allows you access to the airway to secure adequate ventilation. Most football face guards are fastened to the helmet by four plastic clips, which can be cut with a sharp knife or unscrewed with a screwdriver to remove the face guard, as shown in Skill Drill 15-10: Stabilize the patient\u2019s head and helmet in a neutral, in-line position Step 1. Then remove the mask in one of two ways: A. Unscrew the retaining clips for the face mask Step 2. B. Use a trainer\u2019s tool designed for cutting retaining clips Step 3. Assess the patient\u2019s airway.\n\nThe second indication for helmet removal is a loose helmet that will not ensure adequate immobilization of the head when secured to the spinal immobilization device. A loose helmet can be removed easily while the head and neck are being stabilized manually. The procedure for helmet removal in this circumstance is shown in Skill Drill 15-11. Note that this procedure requires two experienced people.\n1. Kneel down at the patient\u2019s head and open the face shield so that you can assess the airway and breathing. Remove the eyeglasses if the patient is wearing them.\n2. Stabilize the helmet by placing your hands on either side of it, ensuring that your fingers are on the patient\u2019s lower jaw to prevent movement of the head. Your partner can then loosen the strap Step 1.\n3. After the strap is loosened, your partner should place one hand on the patient\u2019s lower jaw and the other behind the head at the occiput Step 2.\n4. Once your partner\u2019s hands are in position, gently slip the helmet off about halfway and then stop Step 3.\n5. Have your partner slide his or her hand from the occiput to the back of the head to prevent the head from snapping back once the helmet is removed Step 4.\n6. With your partner\u2019s hand in place, remove the helmet and stabilize the cervical spine. Apply a cervical collar and then secure the patient to a long backboard Step 5. Note: With large helmets or small patients, you may need to pad under the shoulders.",
        "Injuries of the Chest": "The chest cavity contains the lungs, the heart, and several major blood vessels. The cavity is surrounded and protected by the chest wall, which is made up of the ribs, cartilage, and associated chest muscles common chest injuries are fractures of the ribs, flail chest, and penetrating wounds.",
        "Fractures of the Ribs": "Injury may produce fracture of one or more ribs. Even a simple fracture of one rib produces pain at the site of the fracture and difficulty breathing. Multiple rib fractures result in significant breathing difficulty. The pain may be so intense that the patient cannot breathe deeply enough to take in adequate amounts of oxygen. Rib fractures may be associated with injury to the underlying organs. To determine whether a rib is bruised or broken, apply some pressure to another part of the rib. Pain in the injured area indicates a bruise, crack, or fracture. If the injury is to the side of the chest, place one hand on the front of the chest and the other on the back and gently squeeze. To check an injury to the front or back of the rib cage, put your hands on either side of the chest and gently squeeze. If there is no pain, the rib is probably not broken. In patients with rib fractures, be alert for signs and symptoms of internal injury, particularly shock.",
        "Treatment of Rib Fractures": "Try to reassure and make a patient with rib fractures more comfortable by placing a pillow against the injured ribs to splint them. Prevent excessive movement of the patient as you prepare for transport to an appropriate medical facility. Administer oxygen if it is available and you are trained to use it.",
        "Flail Chest": "If three or more ribs are broken in at least two places, the injured portion of the chest wall does not move at the same time as the rest of the chest. The injured part bulges outward when the patient exhales and moves inward when the patient inhales. This condition is called a flail chest.\n\nA flail chest decreases the amount of oxygen and carbon dioxide exchanged in the lungs, and it causes breathing problems that will progressively worsen.\n\nYou can identify a flail chest by examining the chest wall and observing chest movements during breathing. If the injured portion of the chest moves inward as the rest of the chest moves outward (and vice versa), the patient has a flail chest.",
        "Treatment of Flail Chest": "If the patient is having difficulty breathing, do not attempt to restrict the movement of the chest while the patient is inhaling. It may be helpful to support the patient\u2019s breathing with positive pressure ventilation. This can be done by using a bag valve mask and supplemental oxygen. Monitor and support the patient\u2019s ABCs and arrange for prompt transport to an appropriate medical facility.",
        "Penetrating Chest Wounds": "If an object (usually a knife or bullet) penetrates the chest wall, air and blood escape into the space between the lungs and the chest wall. The air and blood cause the lung to collapse. Lung collapse greatly reduces the amount of oxygen and carbon dioxide that is exchanged and can result in shock and death. Blood loss into the chest cavity can produce shock.\nTreatment of Penetrating Chest Wounds\nQuickly seal an open chest wound with a material that will prevent more air from entering the chest cavity. (Occlusive dressings are discussed in Chapter\n\nYou can use petroleum jelly-impregnated gauze, aluminum foil, plastic wrap, or a latex glove. In rare cases, sealing the wound may increase the patient\u2019s breathing difficulty. If it is harder for a patient to breathe after you seal the wound, uncover one corner of the occlusive dressing to see if the breathing improves. Administer oxygen if it is available and you are trained to use it. If a knife or other object is impaled in the chest, do not remove it. Seal the wound around the object with a dressing to prevent air from entering the chest. Stabilize the impaled object with bulky dressings.\n\nAny chest injury that results in air leakage and bleeding requires prompt attention. For these reasons, patients with severe chest injuries require rapid transport to an appropriate medical facility.\n\nA conscious patient with chest trauma may demand to be placed in a sitting position to ease breathing. Unless you must immobilize the spine or treat the patient for shock, help the patient assume whatever position eases his or her breathing. If oxygen is available, administer it. If the patient\u2019s respirations are excessively slow or absent, perform mouth-to-mask breathing. A bag valve mask may also be used by trained personnel. If the patient\u2019s heart stops, begin chest compressions, regardless of whether there are chest injuries.",
        "Prep Kit-Ready for Review": "Musculoskeletal injuries are caused by three types of mechanism of injury: direct force, indirect force, and twisting force.\nA fracture is a broken bone. Fractures can be closed (the bone is broken but there is no break in the skin) or open (the bone is broken and the overlying skin is lacerated).\nA dislocation is a disruption that tears the supporting ligaments of the joint.\nA sprain is a joint injury caused by excessive stretching of the supporting ligaments.\nThe three steps in examining a patient with a limb injury include: General assessment of the patient Examination of the injured part Evaluation of the circulation, sensation, and movement in the injured limb\nRegardless of their extent or severity, treat all limb injuries the same way in the field. For all open extremity wounds, first cover the entire wound with a dry, sterile dressing. Then apply firm but gentle pressure to control bleeding, if necessary. Then splint the injured limb. \nThe three basic types of splints are rigid, soft, and traction.\nIt takes two people to splint most limb injuries adequately: one to stabilize and support the extremity and one to apply the splint.\nSevere head and spinal cord injuries can result from many different kinds of trauma. These injuries are common causes of death and can lead to irreversible paralysis and permanent brain damage.\nInjuries of the head are classified as open or closed. In a closed head injury, bleeding and swelling within the skull may increase pressure on the brain, leading to irreversible brain damage. An open injury of the head usually bleeds profusely.\nWhen a sign or symptom of a head injury is present, immobilize the head and stabilize the patient\u2019s neck; maintain an open airway; support breathing; monitor circulation; check to see if cerebrospinal fluid or blood is seeping; control bleeding with dry, sterile dressings; treat other serious injuries; and arrange for prompt transport.\nAirway obstruction is the primary danger in severe facial injuries.\nWhen facial injuries are present, immobilize the head and stabilize the patient\u2019s neck; maintain an open airway; support breathing; monitor circulation; control bleeding with a dry, sterile dressing and apply direct pressure; treat other serious injuries; and arrange for prompt transport.\nWhen you suspect a spinal injury, do not move the patient during the examination. Further, do not allow the patient to move.\nWhen a sign or symptom of spinal injury is present, place the head and neck in a neutral position; stabilize the head and prevent movement of the neck; maintain an open airway; support breathing; monitor circulation; assess pulse, movement, and sensation; examine and treat other serious injuries; assist in immobilizing the patient using a long or short backboard; and arrange for prompt transport.\nThe most common chest injuries are rib fractures, flail chest, and penetrating wounds.",
        "Vital Vocabulary": "abdominal breathing: Breathing using only the diaphragm., arm: The upper portion of the upper extremity; from the shoulder to the elbow., cerebrospinal fluid (CSF): A clear, watery, straw-colored fluid that fills the space between the brain and spinal cord and their protective coverings., closed fracture: A fracture in which the overlying skin has not been damaged., closed head injury: Injury where there is bleeding and/or swelling within the skull., concussion: A closed head injury that alters the way the brain functions; symptoms of a concussion include headache, loss of memory, and confusion., dislocation: Disruption of a joint so that the bone ends are no longer in alignment., flail chest: A chest injury in which three or more ribs are broken in two or more places, resulting in the injured part of the chest moving in the opposite direction from the rest of the chest., forearm: The lower portion of the upper extremity; from the elbow to the wrist., joint: The point where two bones come in contact with each other., leg: The lower portion of the lower extremity; from the knee to the foot., mechanism of injury (MOI): The means by which a traumatic injury occurs., open fracture: Any fracture in which the overlying skin has been damaged., osteoporosis: Abnormal brittleness of the bones in older people caused by loss of calcium; affected bones fracture easily., paralysis: Inability of a conscious person to move voluntarily., rigid splint: Splint made from firm materials such as wood, aluminum, or plastic., seizure: Sudden episode of uncontrolled electrical activity in the brain., sling: A bandage or material that helps to support the weight of an injured upper extremity., soft splint: A splint made from supple material that provides gentle support., sprain: A joint injury in which the joint is partially or temporarily dislocated and some of the supporting ligaments are either stretched or torn., thighbone: The upper portion of the lower extremity; from the hip joint to the knee., traction splint: A splint that holds a lower extremity fracture in alignment by applying a constant, steady pull on the extremity., trauma: A wound or injury, either physical or psychological., vacuum splint: A soft splint that becomes rigid when air is removed from the splint."
    },
    {
        "Introduction": "This chapter presents the skills you need to recognize and care for patients who are experiencing shock, are bleeding, or have soft-tissue injuries. Because most soft-tissue injuries result in bleeding, maintaining good standard precautions is important when you are caring for patients with these types of injuries. The chapter describes four types of soft-tissue wounds: abrasions, lacerations, punctures, and avulsions. Techniques for controlling external bleeding are discussed, and you will learn the various techniques for dressing and bandaging wounds.\n\nDamage to internal soft tissues and organs can cause life-threatening conditions. Internal bleeding causes blood loss in the circulatory system and results in shock. Shock is a state of collapse of the cardiovascular system that results in inadequate delivery of blood to the organs. More trauma patients die from shock than from any other condition. Your ability to recognize the signs and symptoms of shock and to take simple measures to aid shock patients will give them the best chance for survival. This chapter explains the causes and types of shock using an analogy of a pump, pipes, and fluid. You will learn how the failure of any part of the system can cause shock. \n\nBurns are another type of soft-tissue injury. \n\nBurns may be caused by heat, chemicals, or electricity. They may damage any part of the body and are especially harmful if they occur inside the respiratory tract. This chapter examines the extent, depth, and cause of burns.",
        "Patient Assessment for Bleeding, Shock, and Soft-Tissue Injuries": "It is important to follow the steps of the patient assessment sequence described in Chapter 9, Patient Assessment, when caring for patients who are bleeding, are in shock, or have soft-tissue injuries. Your scene size-up needs to include all the steps you learned previously to ensure safety for you and your patient. When performing the primary assessment, you may need to temporarily halt the assessment if the patient is losing a significant amount of blood. However, once you have managed this problem, you should immediately return to completing the assessment sequence, performing all the remaining steps to ensure no problems or injuries are overlooked. During your secondary assessment, be alert for any signs and symptoms of shock from internal or external blood loss. When obtaining a SAMPLE history, ask the patient whether he or she is using a blood thinner, which may interfere with blood clotting. When performing a reassessment, watch the patient for signs and symptoms of shock such as pale skin, increasing pulse rate, or decreasing blood pressure. For trauma patients, you will usually perform the secondary assessment before you obtain the SAMPLE history. Review the patient assessment sequence shown in Figure 14-1.",
        "Safety": "Most soft-tissue injuries involve some degree of bleeding. Always maintain standard precautions when you approach a patient with a potential soft-tissue injury.",
        "Standard Precautions and Soft-Tissue Injuries": "The concept of standard precautions assumes all body fluids are potentially infectious. Therefore, take appropriate measures to prevent contact with the patient\u2019s body fluids. Wear gloves to prevent contact with the patient\u2019s blood when caring for patients who have soft-tissue injuries. At times, you may also need to wear a surgical mask and eye protection if there is danger of blood splatter from a massive wound or if the patient is coughing or vomiting bloody material.",
        "Parts and Function of the Circulatory System": "The three parts of the circulatory system are the pump (heart), the pipes (arteries, veins, and capillaries), and the fluid (blood cells and other blood components).",
        "The Pump": "The heart functions as the human circulatory system\u2019s pump. The heart consists of four separate chambers: the two upper chambers on the top of the heart are called the left and right atria (a single chamber is called an atrium), and the two lower chambers on the bottom of the heart are called the left and right ventricles. The ventricles are the larger chambers and do most of the actual pumping. The atria are somewhat less muscular and serve as reservoirs for blood flowing into the heart from the body and the lungs.",
        "The Pipes": "The human body has three main types of blood vessels: arteries, capillaries, and veins. The arteries (big-flow, heavy-duty, high-pressure pipes) carry blood away from the heart. The capillaries (distribution pipes), the smallest of the blood vessels, form a network that distributes blood to all parts of the body. The smallest capillaries are so narrow that blood cells have to flow through them single file. The veins return the blood from the capillaries to the heart, where it is pumped to the lungs. There, the blood gives off carbon dioxide and absorbs oxygen.",
        "Fluid": "Fluid in the circulatory system consists of blood cells and other blood components, each with a specific function. The liquid part of the blood is known as plasma. Plasma serves as the transporting medium for the solid parts of the blood, which are the red blood cells, white blood cells, and platelets. Red blood cells carry oxygen and carbon dioxide. White blood cells have a'search and destroy' function. They consume bacteria and viruses to combat infections in the body. Platelets interact with each other and with other substances in the blood to form clots that help stop bleeding.",
        "Pulse": "A pulse is the pressure wave generated by the pumping action of the heart. With each heartbeat, there is a surge of blood from the left ventricle as it contracts and pushes blood out into the main arteries of the body. When you are counting the number of pulsations per minute, what you are actually counting is each heartbeat per minute. In other words, the pulse rate reflects the heart rate. Usually you can feel a patient\u2019s radial and carotid pulses. In a conscious patient, you can easily find the radial (wrist) pulse at the base of the thumb. If the patient is unconscious, experiencing shock, or both, it may be impossible for you to feel a radial pulse. Therefore, it is vital that you know how to locate the carotid (neck) pulse. If the patient appears to be in shock or is unconscious, attempt to locate the carotid pulse first. To locate the carotid pulse, place two fingers lightly on the larynx and slide the fingers off to one side until you feel a slight notch on the neck. You should be able to feel the carotid pulse at this location. Practice locating the carotid pulse of another person in a dark room. You should be able to locate the pulse within 3 seconds of touching the person\u2019s larynx.",
        "Shock": "Shock is failure of the circulatory system. Circulatory failure has many possible causes, but the three primary causes are discussed here.",
        "Pump Failure": "Cardiogenic shock occurs if the heart cannot pump enough blood to supply the needs of the body. Pump failure can result if the heart has been weakened by a heart attack. Inadequate pumping of the heart can cause blood to back up in the vessels of the lungs, resulting in a condition known as congestive heart failure (CHF).",
        "Special Populations 1": "In an infant, check the brachial (upper arm) pulse instead of the carotid pulse.",
        "Pipe Failure": "Pipe failure is caused by the expansion (dilation) of the capillaries to as much as three or four times their normal size. This causes blood to pool in the capillaries, instead of circulating throughout the system. When blood pools in the capillaries, the rest of the body, including the heart and other vital organs, is deprived of blood. Blood pressure falls and shock results. Blood pressure is the pressure of the circulating blood against the walls of the arteries. In shock caused by sudden expansion of the capillaries, blood pressure may drop so rapidly in your patient that you are unable to feel either a radial or a carotid pulse.\n\nThe least serious type of shock caused by pipe failure is fainting. Fainting, a form of psychogenic shock, is the body\u2019s response to a major psychological or emotional stress. As the nervous system reacts, the capillaries suddenly expand to three or four times their normal size. Blood then pools in the dilated vessels, resulting in reduced blood supply to the brain. Fainting is a short-term condition that corrects itself once the patient is placed in a horizontal position.\n\nAnaphylactic shock is caused by an extreme allergic reaction to a foreign substance, such as venom from bee stings, penicillin, or certain foods. Shock may develop very quickly following exposure. The patient may suddenly start to sneeze or itch, a rash or hives may appear, the face and tongue may swell very quickly, and a blue color may appear around the mouth. The patient appears flushed (red) and breathing may quickly become difficult, with wheezing sounds coming from the chest. Blood pressure drops rapidly as the blood pools in the expanded capillaries. The pulse may be so weak that you cannot feel it. Pipe failure has occurred and death will result if prompt action to counteract the toxin is not taken.\n\nSpinal shock may occur in patients who have sustained a spinal cord injury. The injury to the spinal cord allows the capillaries to expand, and blood pools below the level of the injury. The brain, heart, lungs, and other vital organs are deprived of blood, resulting in shock",
        "Words of Wisdom.": "Three types of shock caused by capillary expansion are as follows: \n1. Shock induced by fainting \n2. Anaphylactic shock \n3. Spinal shock",
        "Fluid Loss": "The third general type of shock is caused by fluid loss. Fluid loss caused by excessive bleeding (hemorrhage) is the most common cause of shock. Blood escapes from the normally closed circulatory system through an internal or external wound, and the system\u2019s total fluid level (blood volume) drops until the pump cannot operate efficiently. To compensate for fluid loss, the heart begins to pump faster to maintain pressure in the pipes. However, as the fluid continues to drain out, the pump eventually stops pumping altogether, resulting in cardiac arrest.\n\nExternal bleeding is not difficult to detect because you can see blood escaping from the circulatory system to the outside of the patient\u2019s body. With internal bleeding, blood escapes from the system, but usually the bleeding cannot be seen. However, you may see signs of internal blood loss, such as bruising, swelling, and rigidity in the affected area. If the patient is conscious, he or she may report severe pain in the immediate area. Even though the escaped blood remains inside the body, it cannot reenter the circulatory system and it is not available to be pumped by the heart. Whether the bleeding is external or internal, if it remains unchecked, the result will be shock, eventual pump failure, and death.\n\nAn average adult has about 12 pints (6 L) of blood circulating in the system. The loss of a single pint of blood will not produce shock in a healthy adult. In fact, 1 pint (0.5 L) per donor is the amount that blood banks collect. However, the loss of 2 or more pints (1 L or more) of blood can produce shock. This amount of blood loss can result from such injuries as a fractured femur.",
        "Signs and Symptoms of Shock": "Shock deprives the body of sufficient blood to function normally. As shock progresses, the body alters some of its functions in an attempt to maintain sufficient blood supply to its vital parts. A patient who is in shock may exhibit some or all of the signs and symptoms shown in the box below. Initially, the patient\u2019s breathing may be rapid and deep, but as shock progresses in severity, breathing becomes rapid and shallow. Changes in mental status may be the first signs of shock; therefore, monitoring the overall mental status of a patient can help you detect shock. Any change in mental status may be significant. In severe cases of shock, the patient loses consciousness. If a trauma patient who has been quiet suddenly becomes agitated, restless, and vocal, you should suspect shock. If a trauma patient who has been loud, vocal, and aggressive becomes quiet, you should also suspect shock and begin treatment. If the patient has dark skin, you may not be able to use skin color changes to help you detect shock. Therefore, be especially alert for other signs of shock. The capillary refill test and the condition of the skin (cool and clammy) will help you recognize shock in patients who have dark skin.",
        "Signs and Symptoms": "Signs and symptoms of shock include:\nConfusion, agitation, restlessness, or anxiety\nCold, clammy, sweaty, pale skin\nRapid, shallow breathing\nRapid, weak pulse\nIncreased capillary refill time\nNausea or vomiting\nWeakness or fainting\nThirst",
        "General Treatment for Shock": "As an emergency medical responder (EMR), you can combat shock from any cause and keep it from getting worse by taking several simple but important steps. Remember that the protocols for use of these skills may vary. Always follow the protocols approved by your medical director.",
        "Treatment": "Follow these steps for the general treatment of shock: 1. Position the patient correctly \n2. Maintain the patient\u2019s ABCs3 \n3. Treat the cause of shock, if possible\n 4.Maintain the patient\u2019s body temperature by placing blankets under and over the patient\n5. Ensure the patient does not eat or drink anything\n6. Assist with other treatments (such as administering oxygen, if available) 7. Arrange for immediate and prompt transport to an appropriate medical facility",
        "Position the Patient Correctly": "If the patient has no head injury, extreme discomfort, or difficulty breathing, place the patient flat on his or her back (supine) on a horizontal surface. Place a blanket under the patient, if available. Elevate the patient\u2019s legs according to local protocol. If the patient has a head injury, spine injury, or lower extremity injury, position the patient flat on his or her back. If the patient is having chest pain or difficulty breathing (which is likely to occur in cases of heart attack and emphysema) and no spinal injury is suspected, place the patient in a sitting or semireclining position.",
        "Treatment_0": "Do not allow a patient in shock to stand!",
        "Maintain the Patient\u2019s ABCs": "Check the patient\u2019s airway, breathing, and circulation (ABCs) at least every 5 minutes. If necessary, open the airway, perform rescue breathing, or begin cardiopulmonary resuscitation (CPR).",
        "Treat the Cause of Shock, if Possible": "Most patients who are in shock must be treated in the hospital, with care provided by specially trained physicians. However, you are able to treat one common cause of shock\u2014external bleeding. By controlling external bleeding with direct pressure, elevation, tourniquet, or pressure points, you can treat this cause of shock temporarily until the patient can be transported to an appropriate medical facility for more advanced treatment.",
        "Maintain the Patient\u2019s Body Temperature": "Attempt to keep the patient comfortably warm. A patient with cold, clammy skin should be covered. It is as important to place blankets under the patient to keep body heat from escaping into the ground as it is to cover the patient with blankets.",
        "Do Not Allow the Patient to Eat or Drink": "Even though a patient in shock is often very thirsty, do not give liquids by mouth. There are two reasons for this rule:\n1. A patient in shock may be nauseated and eating or drinking may cause vomiting.\n2. A patient in shock may need emergency surgery. Patients should not have anything in their stomachs before surgery.\nIf you are working in an area where ambulance response time is more than 20 minutes, you may give patients a clean cloth or gauze pad that has been soaked in water to suck on. This relieves dryness of the mouth but does not quench thirst. No matter how thirsty patients are, do not permit them to drink anythiTreatmentng.",
        "Treatment_1": "In the summer or in hot environments, it is not necessary to cover every shock patient with blankets. You are trying to maintain body heat, not produce more.",
        "Assist With Other Treatments": "When an advanced life support (ALS) unit arrives at the scene, be ready to assist them with further treatment. Patients may be given oxygen or IV solutions. If you are trained in the administration of oxygen and have it available, provide it to shock patients. Oxygen benefits shock patients by ensuring that the reduced number of red blood cells are as oxygen saturated as they can be. Advanced emergency medical technicians (AEMTs) or paramedics can administer intravenous (IV) fluids. Adding fluid to the body combats the loss of blood volume. Although rare, some emergency medical services (EMS) personnel sometimes use pneumatic anti-shock garments (PASGs) in the field to treat pelvic fractures; however, PASGs are no longer favored for shock treatment. PASGs are placed around the patient\u2019s legs and abdomen and inflated with air. As the PASG inflates, it exerts pressure around the legs and abdomen. Although, as an EMR, you will not use these devices yourself, you should know their purpose and function. It is also important to understand that PASGs must not be removed in the field. Removing PASGs must be done in a hospital and under the direct supervision of a physician.",
        "Arrange for Transport": "As soon as you determine that you have a patient who is in shock, make sure an ambulance has been dispatched. When the ambulance arrives, give EMS personnel a concise handoff report, emphasizing the signs and symptoms of shock that you noted. The EMS personnel will then ensure the patient is quickly prepared for prompt transport to an appropriate medical facility that can handle a patient with this type of condition. Usually, the most appropriate treatment for a patient in shock that is the result of injury or bleeding is surgical repair, and the sooner the patient gets to the hospital, the better the chance of his or her survival.",
        "Words of Wisdom": "A quiet patient is often a patient who is in shock. Other times, when you have a patient who suddenly becomes agitated, shock may be developing. Watch all patients carefully for signs of shock!",
        "Treatment for Shock Caused by Pump Failure": "Patients experiencing pump failure may be confused, restless, anxious, or unconscious. Their pulse is usually rapid and weak, and their skin is cold and clammy, sweaty, and pale. Their respirations are often rapid and shallow. Pump failure is a serious condition. Your proper treatment and prompt transport by ambulance to an appropriate medical facility will give these patients their best chance for survival.",
        "Treatment for Shock Caused by Pipe Failure": "Patients who have fainted, who are experiencing anaphylactic shock, or who have sustained a severe spinal cord injury will have pipe failure. Their capillaries may increase three or four times the normal size, causing signs and symptoms of shock.",
        "Treatment for Anaphylactic Shock": "The initial treatment for anaphylactic shock is similar to the treatment for any other type of shock. Anaphylactic shock is an extreme emergency, and the patient must be transported as soon as possible. Paramedics, nurses, and physicians can administer medications that may reverse the allergic reaction.\n\nSome patients who have severe allergies may carry an epinephrine auto-injector. If the patient has a prescribed auto-injector, you can administer the epinephrine if you have been trained in its use and have permission from your local medical director. Be aware of and follow your local protocols. Support the patient\u2019s thigh and place the tip of the auto-injector lightly against the outer thigh. Using a quick motion, push the auto-injector firmly against the thigh and hold it in place for several seconds. This will inject the medication.",
        "Treatment for Shock Caused by Fluid Loss": "Shock may be caused by internal blood loss (blood that escapes from damaged blood vessels and stays inside the body) or by external blood loss (blood that escapes from the body). Excessive bleeding is the most common cause of shock.",
        "Signs and Symptoms of internal bleeding": "Signs and symptoms of internal bleeding include the following:\nCoughing or vomiting of blood\nAbdominal tenderness, rigidity, bruising, or distention\nRectal bleeding\nVaginal bleeding in women\nClassic signs of shock",
        "Shock Caused by Internal Blood Loss": "Patients can die quickly and quietly from internal bleeding following abdominal injuries that rupture the spleen, liver, or large blood vessels. You must be alert to detect the earliest signs and symptoms of internal bleeding and to begin treatment for shock. If you are treating several injured patients, those with internal bleeding should be transported first to the medical facility because immediate surgery may be needed. If you are treating several injured patients, those with internal bleeding should be transported first to the medical facility because immediate surgery may be needed. (\nBleeding from stomach ulcers, ruptured blood vessels, or tumors can cause internal bleeding and shock. This bleeding can be spontaneous, massive, and rapid, often leading to the loss of large quantities of blood by vomiting or bloody diarrhea.\nIt is important to recognize the signs and symptoms of internal bleeding and take prompt corrective action. In addition to the classic signs of shock (confusion, rapid pulse, cold and clammy skin, and rapid breathing), patients with internal bleeding may show additional signs and symptoms as depicted in the Signs and Symptoms box on this page.",
        "Treatment_3": "You cannot stop internal bleeding. You can only treat its symptoms and arrange for the patient to be promptly transported to an appropriate medical facility.",
        "Bleeding": "Blood loss can occur through external bleeding, which is visible, or through internal bleeding, which can be hard to detect. It ranges from minor cuts to massive blood loss that can kill a person in a few minutes. As an EMR, it is important for you to be able to recognize the signs and symptoms of external bleeding and internal bleeding. It is also important for you to know what steps to take to control bleeding and what care you can administer for patients who are experiencing internal blood loss and shock.",
        "Words of Wisdom_4": "Patients who regularly consume large quantities of alcohol are at high risk for internal bleeding. Heavy alcohol consumption damages the liver and reduces the production of clotting factors and platelets. Because platelets are needed for blood coagulation and clotting, these patients can experience life-threatening internal bleeding from relatively minor injuries. According to the Centers for Disease Control and Prevention (CDC), in 2013, 36,427 deaths were reported from liver failure. Remember that patients with liver disease are at a high risk for bleeding because liver disease interferes with blood clotting. Alcohol also irritates the digestive system, which makes patients with alcoholism more likely to experience life-threatening bleeding from the esophagus or stomach.",
        "Controlling External Blood Loss": "This section describes how to control external blood loss using direct pressure, elevation, tourniquets, and pressure points. Follow your local protocols for bleeding control. Some protocols may not permit the use of all these methods. They are all included because each technique may be beneficial to patients under certain circumstances. There are three types of external blood loss: capillary, venous, and arterial. The most common type of external blood loss is capillary bleeding. In capillary bleeding, the blood oozes out (such as from a cut finger). You can control capillary bleeding simply by applying direct pressure to the site.\n\nThe next most common type of bleeding is venous bleeding. This type of bleeding has a steady flow. Bleeding from a large vein may be profuse and life threatening. To control venous bleeding, apply direct pressure to the site for at least 5 minutes.\n\nThe most serious type of bleeding is arterial bleeding\n\nArterial blood spurts or surges from the laceration or wound with each heartbeat. Blood pressure in arteries is higher than in capillaries or veins, and unchecked arterial bleeding can result in death from loss of blood in a short time. To control arterial bleeding, exert and maintain direct pressure on the site, sufficient to stop the flow of blood, until EMS arrives. If available and permitted under your local protocol, apply a tourniquet between the heart and the site of the arterial bleeding.\n\nBecause many injured patients actually die from shock caused by blood loss, it is vitally important that you control external bleeding quickly",
        "Treatment_5": "Follow these steps to treat shock caused by pump failure:\n1. Keep the patient lying down unless the patient is able to breathe easier in a sitting position.\n2. Maintain the patient\u2019s ABCs. Be prepared to perform CPR, if necessary.\n3. Maintain the patient\u2019s normal body temperature.\n4. Ensure the patient does not eat or drink anything.\n5. Keep the patient quiet and do any necessary moving for him or her.\n6. Provide reassurance.\n7. Arrange for prompt transport by ambulance to an appropriate medical facility.\n8. Provide high-flow oxygen as soon as it is available.\n\nFollow these steps to treat shock caused by pipe failure: \nFainting 1. Examine the patient to ensure there is no injury.\n2. Keep the patient lying down and elevate the legs if indicated by local protocol.\n3. Maintain the ABCs.\n4. Maintain the patient\u2019s normal body temperature.\n5. Provide reassurance.\nAnaphylactic Shock: 1. Keep the patient lying down and elevate the legs if indicated by local protocol. 2. If the patient has an epinephrine auto-injector, help the patient use it if indicated by local protocol.\n\nMaintain the patient\u2019s ABCs. Anaphylactic shock may cause airway swelling. In severe reactions, the patient may require mouth-to-mask breathing or full CPR. Maintain the patient\u2019s normal body temperature. Provide reassurance. Arrange for rapid transport by ambulance to an appropriate medical facility.\nSpinal Shock: Place the patient on his or her back. Because the spine may be injured, keep the patient\u2019s head and neck stabilized to protect the spinal cord.  Mantain the patient\u2019s ABCs. Maintain the patient\u2019s normal body temperature. Ensure the patient does not eat or drink anything. Assist with other treatments. Help other medical providers place the patient on a backboard.\n\n Follow these steps to treat shock caused by fluid loss: Internal Blood Loss Keep the patient lying down and elevate the legs if indicated by local protocol. Maintain the patient\u2019s ABCs. Maintain the patient\u2019s normal body temperature. Ensure the patient does not eat or drink anything. Provide reassurance. Keep the patient quiet and do any necessary moving for him or her. Provide high-flow oxygen as soon as it is available. Monitor the patient\u2019s vital signs at least every 5 minutes. Arrange for prompt transport by ambulance to an appropriate medical facility. \n\nExternal Blood Loss: Control bleeding by applying direct pressure on the wound, elevating the injured part, and applying a tourniquet if one is available and permitted under your local protocols. Controlling bleeding using one of these methods is the most important step. Maintain standard precautions.\n\nEnsure the patient is lying down and elevate the legs if indicated by local protocol. Maintain the patient\u2019s ABCs. Maintain the patient\u2019s normal body temperature. Ensure the patient does not eat or drink anything. Provide reassurance. Provide high-flow oxygen as soon as it is available. Arrange for prompt transport by ambulance to an appropriate medical facility.",
        "Treatment_6": "Three methods of controlling external bleeding are as follows:\n1. Apply direct pressure.\n2. Elevate the injured body part.\n3. Apply a tourniquet if permitted and if available.",
        "Direct Pressure": "Most external bleeding can be controlled by applying direct pressure to the wound. Place a dry, sterile dressing directly on the wound and apply pressure to the wound with your gloved hand. Wear the gloves from your EMR life support kit. If you do not have a sterile dressing or gauze bandage, use the cleanest cloth available. Wrap the dressing and wound snugly with a roller gauze bandage to maintain direct pressure on the wound. Do not remove a dressing after you have applied it. If the dressing becomes blood soaked, place another dressing on top of the first and keep them both in place.",
        "Elevation": "If direct pressure does not stop external bleeding from an extremity, elevate the injured arm or leg as you maintain direct pressure. Elevation, in conjunction with direct pressure, will usually stop severe bleeding.",
        "Words of Wisdom_7": "Recent military research has resulted in the development of effective blood clotting or hemostatic agents. These are usually impregnated in gauze dressings or supplied as a powder. These agents can be packed into a wound and aid in the formation of a blood clot in a shorter period of time. The use of these clotting agents is usually not recommended for some wounds involving the head, neck, chest, or abdomen. They are useful for extremity wounds and for wounds in junctional areas, such as the groin, shoulder and armpit, or neck, where a tourniquet cannot be applied. Hemostatic agents are carried by some EMS agencies and are carried in special kits by some law enforcement agencies for rapid treatment of gunshot wounds. Use these clotting agents only if you have received special training and are permitted by your local protocols.",
        "Tourniquets": "Use tourniquets in any situation where extremity bleeding cannot be easily and immediately controlled by direct pressure or elevation. High-velocity gunshot wounds and explosive devices can sever arteries in the arm or the leg. These types of injuries result in rapid and profound blood loss that lead to death within minutes. These devastating types of wounds occur in military combat situations and in noncombat situations where high-velocity weapons are used by civilians or law enforcement personnel. Recent military experience in combat situations has resulted in some changes regarding the use of tourniquets. To reduce deaths from these types of wounds, the military has developed and adopted several modern versions of tourniquets that use simple laws of physics to apply sufficient pressure quickly and easily to stop life-threatening bleeding. These updated tourniquets can be applied in less than 1 minute. Because the tourniquets multiply the force you place on them, they require you to use only one hand to apply.\n\nRecent medical research indicates that a tourniquet can be applied and left in place for up to 2 hours without causing additional damage to the injured limb. This means that the use of tourniquets seems to have great benefit to the patient without incurring a high risk of further damage to the limb. Some EMS agencies teach their personnel the indications for the use of these tourniquets and how to apply them properly. You should use tourniquets once you have completed proper instruction and have protocols in place that have been approved by your medical director.\n\nFollow the steps in Skill Drill 14-1 to control bleeding with a tourniquet: Step 1. Apply direct pressure with a sterile dressing. Step 2. Apply a pressure dressing. Step 3. Apply a tourniquet above the level of bleeding",
        "Words of Wisdom_8": "Pressure points should never be used as a tool to control hemorrhage in place of a tourniquet if one is available or if one can be improvised using readily available materials.",
        "Safety_9": "To prevent coming into contact with any blood that is present, wear gloves and other protective devices as necessary.",
        "Pressure Points": "Pressure points should be used for extremity wounds if direct pressure and elevation do not control the bleeding and only if you are not permitted to use a tourniquet (or if a tourniquet is not available). Pressure points can be difficult to use to control hemorrhage and are not always effective. However, using pressure points to attempt to control bleeding requires no special equipment and should be considered in cases where other options are unavailable. For injuries too near to the body to allow for tourniquet application (for example, injuries that are too proximal or too close to the trunk to apply a tourniquet [junctional injuries]), direct pressure and use of pressure points may be effective. Tourniquets, however, can be improvised when commercially produced options are not available. Options for improvisation include belts and articles of clothing tied around the limb as proximal as possible to the zone of injury. If you have a choice between using a pressure point or a tourniquet to control brisk bleeding in an extremity, use the tourniquet because it is more effective and will lessen the chance that the patient will die from serious hemorrhage.\n\nPressure points may theoretically be able to control bleeding by preventing blood from flowing into a limb. This is accomplished by compressing a major artery against the bone at a specific location, a pressure point. Although there are several pressure points in the body, the brachial artery pressure point (in the upper arm) and the femoral artery pressure point (in the groin) are the most commonly described.\n\nWhen you are applying pressure to the brachial artery, remember the words'slap, slide, and squeeze':\n1. Position the patient\u2019s arm so the elbow is bent at a right angle (90\u00ba) and hold the upper arm away from the patient\u2019s body.\n2. Gently'slap' the inside of the biceps with your fingers halfway between the shoulder and the elbow to push the biceps out of the way.\n3. 'Slide' your fingers up to push the biceps away.\n4. 'Squeeze' (press) your hand down on the humerus (upper arm bone). You should be able to feel the pulse as you press down. \n\nIf the patient is sitting down, squeeze the arm by placing your fingers halfway between the shoulder and the elbow and your thumb on the opposite side of the patient\u2019s arm. If done properly, this technique (in combination with direct wound pressure and elevation) will quickly stop any bleeding below the point of pressure application. The femoral artery pressure point is more difficult to locate and squeeze. Follow these steps to apply pressure to the femoral artery:\n1. Position the patient on his or her back and kneel next to the patient\u2019s hips, facing the patient\u2019s head. You should be on the side of the patient opposite the extremity that is bleeding.\n2. Find the pelvis and place the little finger of your hand closest to the injured leg along the anterior crest on the injured side.\n3. Rotate your hand down firmly into the groin area between the genitals and the pelvic bone. This action compresses the femoral artery and usually stops the bleeding, when combined with elevation and direct pressure over the bleeding site.\n4. If the bleeding does not slow immediately, reposition your hand and try again. To effectively apply brachial and femoral pressure points, you must regularly practice each step of these skills.",
        "Treatment_10": "Do not hesitate to lean into the pressure point.",
        "Standard Precautions and Bleeding Control": "Certain communicable diseases such as hepatitis or HIV can be spread by contact with blood from an infected person. This risk is greatly increased when The infected blood comes into contact with a cut or an open sore on your skin. Although your risk of contracting hepatitis or HIV through intact skin is small, you should minimize this risk as much as possible by wearing nitrile or latex gloves whenever you might come in contact with a patient\u2019s blood or body fluids. Carry your gloves on top of your EMR life support kit or in a pouch on your belt for quick access. If you do get blood on your hands, wash it off as soon as possible with soap and water. If you are in the field and cannot wash your hands, use a waterless hand-cleaning solution that contains an effective germ-killing agent.",
        "Wounds": "A wound is an injury caused by any physical means that leads to damage of a body part. Wounds are classified as closed or open. In a closed wound, the skin remains intact; in an open wound, the skin is disrupted.",
        "Closed Wounds": "The only closed wound is the bruise (contusion). A bruise is an injury of the soft tissue beneath the skin. Because small blood vessels are broken, the injured area becomes discolored and swells. The severity of these closed soft-tissue injuries varies greatly. A simple bruise heals quickly. In contrast, bruising and swelling following an injury may also be a sign of an underlying fracture. Whenever you encounter a significant amount of swelling or bruising, suspect the possibility of an underlying fracture.",
        "Open Wounds": "An open wound is one that results in a break in the skin. There are several types of open wounds, including abrasions, puncture wounds, lacerations, avulsions, and amputations. Each type is described below.",
        "Abrasion": "Commonly called a scrape, road rash, or rug burn, an abrasion occurs when the skin is rubbed across a rough surface.",
        "Puncture": "Puncture wounds are caused by a sharp object that penetrates the skin. These wounds may cause a significant deep injury that is not immediately recognized. Puncture wounds do not bleed freely. If the object that caused the puncture wound remains sticking out of the skin, it is called an impaled object.\n\nA gunshot wound is a special type of puncture wound. The amount of damage done by a gunshot depends on the type of gun used and the distance between the gun and the victim. A gunshot entry wound may appear as an insignificant hole but the bullet can cause massive damage to internal organs. Some gunshot wounds are smaller than a dime, and some are large enough to destroy significant amounts of tissue. Gunshot wounds usually have both an entrance wound and an exit wound. The entrance wound is usually smaller than the exit wound. Most deaths from gunshot wounds result from internal blood loss caused by damage to internal organs and major blood vessels as the bullet passes through the body. There is often more than one gunshot wound. It is important to conduct a thorough patient exam to ensure that you have discovered all of the entrance and exit wounds.",
        "Laceration": "The most common type of open wound is a laceration. Lacerations are commonly called cuts. Minor lacerations may require little care, but large lacerations can cause extensive bleeding and can even be life threatening.",
        "Avulsions and Amputations": "An avulsion is a tearing away of body tissue. The avulsed part may be totally severed from the body or it may be attached by a flap of skin. Avulsions may involve small or large amounts of tissue. If an entire body part is torn away, the wound is called a traumatic amputation. Any amputated body part should be located, placed in a clean plastic bag, kept cool, and taken with the patient to the hospital for possible reattachment (reimplantation). If the amputated part is small and a clean plastic bag is not available, use a surgical glove turned inside out. Use cold packs or ice water to keep the detached body parts cold. Do not allow ice to touch the body part directly.",
        "Treatment_11": "Many older patients with heart conditions are on blood thinners (anticoagulants) to keep blood clots from forming in their body vessels. If they are taking blood thinners, it may take longer to control bleeding from an open wound. As part of your SAMPLE history, ask patients if they are taking any blood thinners.",
        "Principles of Wound Treatment": "Very minor bruises need no treatment. Other closed wounds should be treated by applying ice and gentle compression and by elevating the injured body part. Because extensive bruising may indicate an underlying fracture, splint all major contusions. (Splinting involves using flexible or rigid support to prevent the movement of the injured body part; splinting is discussed more detail in Chapter 15, Injuries to Muscles and Bones.) It is important to stop bleeding as quickly as possible using the cleanest dressing available. You can usually control bleeding by covering an open wound with a dry, clean, or sterile dressing and applying pressure to the dressing with your hand. If the first dressing does not control the bleeding, reinforce it with a second layer. Additional ways to control bleeding include elevating an extremity, applying a tourniquet, and using pressure points. A dressing should cover the entire wound to prevent further contamination. Do not attempt to clean the contaminated wound in the field because cleaning will only cause more bleeding. A thorough cleaning will be done at the hospital. All dressings should be secured in place by a compression bandage.",
        "Treatment_15": "The major principles of open-wound treatment are to: Control bleeding. Prevent further contamination of the wound. Immobilize the injured part (reduce or prevent movement). Stabilize any impaled object.",
        "Treatment_12": "Never remove an impaled object.",
        "Dressing and Bandaging Wounds": "All wounds require bandaging; therefore, you should be familiar with the general principles of applying dressings and bandages to effectively cover and protect wounds.\n\nDressings and bandages are applied to achieve the following\nControl bleeding\nPrevent further contamination\nImmobilize the injured area\nPrevent movement of impaled objects",
        "Dressings": "A dressing is an object placed directly on a wound to control bleeding and prevent further contamination. Once a dressing is in place, apply firm, direct manual pressure on it to stop any bleeding. It is important to stop severe bleeding as quickly as possible using the cleanest dressing available. If no dressing materials are available, you may have to apply direct pressure with your hand to a wound that is bleeding extensively; if this is the case, be sure to observe standard precautions and wear gloves.\n\nSterile dressings come packaged in many different sizes.\n\nThe three most common sizes are gauze squares that measure 4 inches \u00d7 4 inches (10 cm \u00d7 10 cm) (commonly known as 4 \u00d7 4s), heavier pads that measure 5 inches \u00d7 9 inches (13 cm \u00d7 23 cm) (5 \u00d7 9s), and trauma dressings that are thick, sterile dressings that measure 10 inches \u00d7 30 inches (25 cm \u00d7 76 cm). Use a trauma dressing to cover a large wound on the abdomen, neck, thigh, or scalp\u2014or as padding for splints.\n\nWhen you open a package containing a sterile dressing, touch only one corner of the dressing. Place it on the wound without touching the side of the dressing that will be next to the wound. If bleeding continues after you have applied a compression dressing to the wound, put additional gauze pads over the original dressing. Do not remove the original dressing because the blood-clotting process will have already started and should not be disrupted. When you are satisfied that the wound is sufficiently dressed, you can proceed to bandaging the wound.",
        "Treatment_13": "If commercially prepared dressings are not available, use the cleanest cloth object available, such as a clean handkerchief, washcloth, disposable diaper, or article of clothing.",
        "Bandaging": "A bandage is used to hold the dressing in place. Two types of bandages commonly used in the field are roller gauze and triangular bandages. The first type, conforming roller gauze, stretches slightly and is easy to wrap around the body part. Triangular bandages are usually 36 inches (91 cm) across. A triangular bandage can be folded and used as a wide cravat or it can be used without folding. Roller gauze is easier to apply and stays in place better than a triangular bandage, but a triangular bandage is very useful for bandaging scalp lacerations and lacerations of the chest, abdomen, back, or thigh.\n\nFollow certain principles if the bandage is to hold the dressing in place, control bleeding, and prevent further contamination. Before you apply a bandage, check to ensure the dressing covers the wound completely and extends beyond all sides of the wound. Wrap the bandage just tightly enough to control bleeding.\n\nDo not apply it too tightly because it may cut off all circulation. It is important to regularly check circulation at a point farther away from the heart than the injury itself because swelling may make the bandage too tight. If this happens while the patient is under your care, remove the roller gauze or triangular bandage and reapply it, making sure that you do not disturb the dressing beneath.\n\nOnce you have completed applying the bandage, secure it so it cannot slip. Tape, tie, or tuck in any loose ends. Practice bandaging techniques for several types of wounds using both roller gauze and triangular bandages. Although the principles of bandaging are simple, some parts of the body are difficult to bandage. It is important to practice bandaging different parts of the body to ensure competency in emergency medical care situations.",
        "Treatment_14": "Bandaging is a skill that requires practice. Apply bandages tight enough so they stay in place and apply sufficient pressure to stop the bleeding. However, do not apply bandages too tightly or they can occlude circulation to an extremity. Check bandages as part of your reassessment to ensure they are still applied correctly.",
        "Standard Precaution Techniques for the EMR": "Some infectious disease organisms, including the hepatitis and AIDS viruses, can be transmitted if blood from an infected person enters the bloodstream of a healthy person through a small cut or opening in the skin. Because you may have such a cut, it is important to wear gloves to avoid contact with patients\u2019 blood. Wearing gloves also protects wounds from being contaminated by dirt or infectious organisms you may have on your hands. Nitrile or latex medical gloves can be stored on the top of your EMR life support kit or in a pouch on your belt, where they will be readily available. Always wear gloves when in contact with body fluids.",
        "Safety_15": "Providing for your own safety and that of the patient is always a high priority when you are examining and treating open wounds.",
        "Voices of Experience": "His gloved hand had gotten caught in a piece of machinery, and several of his fingers had been amputated.\n\nWe were called to assist the ambulance at an accident at the local paper manufacturing facility. An adult male had his gloved hand caught in a piece of machinery and several of his fingers had been amputated. After we made contact with our patient, we simultaneously determined he had an open airway, was breathing adequately, and was bleeding from his hand. We were able to successfully stop the bleeding with direct pressure, all the while reassuring our patient.\n\nWe radioed ahead to the ambulance to let them know the status of our patient and that four of his fingers had been amputated at the knuckle level. The ambulance in turn requested a helicopter flight meet them at the hospital for rapid transit to a larger, Level One trauma center, which could perform intricate hand surgery.\n\nI found all the fingers (sounds awful, but was not at all), wrapped them in gauze, put them in a plastic bag, and then placed the plastic bag into a container of cold ice water. The patient was transported to the hospital and on to the Level One trauma center.\n\nAbout six months later, the patient made an unexpected visit to my place of business. He asked if I remembered him and I replied, \u201cOf course!\u201d He picked up his hand and waved at me, with all of his fingers intact and perfectly responding. He said, \u201cI just wanted to say hi and say thank you.\u201d\n\nHe was back at work doing the same job, but being much more careful, and truly thankful for the quick action by the emergency medical responders.\n\nEllen A. Mathein, EMT, CPA\nNicolet Area Technical College\nTripoli, Wisconsin",
        "Face and Scalp Wounds": "The face and scalp have many blood vessels. Because of this generous blood supply, a relatively small laceration can result in significant bleeding. Although face and scalp lacerations may not be life threatening, they are always bloody and cause much anxiety for the patient.\n\nYou can control almost all facial or scalp bleeding by applying direct manual pressure. Direct pressure is effective because the bones of the skull are so close to the skin. Direct pressure compresses the blood vessels against the skull and stops the bleeding. If bleeding continues, do not remove the dressing. Instead, reinforce it with a second layer and continue to apply manual pressure. After the bleeding stops, wrap the head with a bandage.\n\nFor wounds inside the cheek Hold a gauze pad inside the cheek (in the mouth). If necessary, apply a pad outside the cheek. Always keep the airway open.\n\nSevere scalp lacerations May be associated with skull fractures or even brain injury. If any brain tissue or bone fragments are visible, do not apply pressure to the wound. Instead, cover the wound loosely, being careful not to exert direct pressure on the brain or the bone fragments.\n\nIf the patient has a head injury, The neck and spine may also be injured. Move the head as little as possible and stabilize the neck. In patients with a head injury, always evaluate the patient\u2019s level of consciousness. Carefully monitor the patient\u2019s airway and breathing and protect the spine.",
        "Words of Wisdom_16": "Remember, patients who have injuries or are bleeding will likely be worried. It is your job to reassure them that you are doing everything you can to treat them. Do not forget to show your patients and their families that you care!",
        "Treatment_17": "If you suspect that a patient may have high blood pressure, the patient must be evaluated by a physician.",
        "Nosebleeds": "Can result from injury, high blood pressure, or dry air. In some cases, there is no apparent cause. A nosebleed with no apparent cause is called a spontaneous nosebleed. In a patient with high blood pressure, increased pressure in the small blood vessels of the nose may cause one to rupture, resulting in bleeding. A patient with high blood pressure should be seen and treated by a physician. Most nosebleeds Can be controlled easily. Unless the patient is experiencing shock, have the patient sit down and tilt his or her head slightly forward. This position keeps the blood from dripping down the throat. Swallowing blood may cause coughing or vomiting and make the nosebleed worse.\n\nAfter the patient is seated correctly, pinch both nostrils together for at least 5 minutes. The patient may wish to do this without assistance. This treatment usually controls nosebleeds. If the nosebleed persists or is very severe, arrange for transport to an appropriate medical facility. Instruct the patient to avoid blowing his or her nose because this will often cause additional bleeding.",
        "Eye Injuries": "All eye injuries are potentially serious and require medical evaluation. When an eye laceration is suspected, cover the entire eye with a dry gauze pad. Have the patient lie on his or her back and arrange for transport to an appropriate medical facility. If a small foreign object is lying on the surface of the patient\u2019s eye, you can use a saline solution, when available, to gently flush the object from the eye. Clean water can also be used, but it tends to irritate the injured eye. Flush from the nose side toward the outside to avoid flushing the object into the other eye. Even small foreign objects can leave a small scratch on the surface of the eye. It is always a good idea to transport the patient to an appropriate medical facility for further assessment and possible treatment. Occasionally an object will be impaled in the eye. Immediately place the patient on his or her back and cover the injured eye with a dressing and a paper cup so the impaled object cannot move. Remember to bandage both eyes. This is an important step to help minimize eye movement because if the patient attempts to look at something with the uninjured eye, the injured eye moves in conjunction, further aggravating the injury. Arrange for transport of the patient to the hospital.",
        "Treatment_18": "Whenever you must bandage both eyes, explain to the patient why you are doing so. Having both eyes covered may be distressing to the patient. Stay with the patient to provide reassurance.",
        "Neck Wounds": "The neck contains many important structures: the trachea, the esophagus, large arteries, veins, muscles, vertebrae, and the spinal cord. Because an injury to any of these structures may be life threatening, all neck injuries are considered serious.\n\nApply direct pressure to control bleeding neck wounds. Once bleeding is controlled, dress the neck. In rare cases, you may have to exert finger pressure above and below the injury site to prevent further neck bleeding.\n\n Always keep in mind that major trauma to the neck may be associated with airway problems and with neck fracture or spinal cord injury. Therefore, maintain the patient\u2019s airway and stabilize the head and neck.",
        "Chest and Back Wounds": "The major organs affected by chest wounds and back wounds are the lungs, large blood vessels, and heart. Any wound involving these organs is a life-threatening injury. Place the patient with a chest injury in a comfortable position (usually sitting). If a lung is punctured, air can escape and the lung can collapse. The patient may cough up bright red blood. To help maintain air pressure in the lung, your first action should be to cover any open chest wound with an airtight material thereby sealing the wound. This covering is called an occlusive dressing. Use a clear plastic cover from your medical supplies, aluminum foil, plastic wrap, gloves, or a special dressing that has been impregnated with petroleum jelly (Vaseline). Any material that will occlude (seal off) the wound is sufficient. \n\nAdministering oxygen is important early treatment for a patient with an injured lung. It should be given by EMS personnel when they arrive or by EMRs who are trained and have the equipment available.\n\nChest wounds may also damage the heart. Seal the wound in the manner described and monitor the patient\u2019s airway, breathing, and circulation. Treat the patient for shock and perform CPR, if necessary. If the patient\u2019s breathing becomes more labored after you seal the chest wound, you may need to remove the seal briefly to allow excess air to escape and then reseal the wound.",
        "Impaled Objects": "If an object is impaled in the patient, apply a stabilizing dressing and arrange for the patient\u2019s prompt transport to an appropriate medical facility. Sometimes an impaled object is too long to permit the patient to be removed from the scene and transported to an appropriate medical facility. In these situations, it may be necessary to stabilize the impaled object and carefully cut it close to the patient\u2019s body. If you encounter a situation like this, stabilize the impaled object as well as you can and immediately request a specialized rescue team that has the tools and training to handle this type of incident.\n\nIf your patient has a knife or other object protruding from the abdomen, do not attempt to remove it. Instead, support the impaled object so it cannot move. Place a large roll of gauze or towels on either side of the object and secure the rolls with additional gauze wrapped around the patient\u2019s body. It is important to stabilize the object so it will not move while the patient is being transported to the hospital.",
        "Closed Abdominal Wounds": "Closed abdominal wounds commonly occur as the result of a direct blow from a blunt object. Check for a closed abdominal wound whenever force has been applied to the abdomen. Look for bruises or other marks on the abdomen that indicate blunt injury.\n\nAny time an injured patient is experiencing shock, you should remember that there may be internal abdominal injuries accompanied by bleeding. When there is internal bleeding, the abdomen may become swollen, rigid, or hard like a board. Treat patients with closed abdominal injuries and signs of shock by placing them on their backs (unless they are having difficulty breathing). Use blankets to help conserve their body heat and elevate the legs if indicated by local protocol. If the patient is vomiting blood (ranging in color from bright red to dark brown), it may be an indication of bleeding from the esophagus or stomach. Monitor the patient\u2019s airway and vital signs carefully because shock may result. Give the patient nothing by mouth. Arrange for prompt transport to an appropriate medical facility.",
        "Special Populations - Septic Shock": "Septic shock is caused by a system-wide infection. It is a very serious condition that can result in rapid decrease of the patient\u2019s blood pressure. It is most common in older adults and people who have weakened immune systems. This recognition and treatment of this condition is discussed more fully in Chapter 18, Geriatric Emergencies.",
        "Bandaging an open abdominal wound.": "A.Place the patient on his or her back with the knees bent to relax the abdominal muscles. B.Cover the injured area with a sterile dressing. Do not attempt to replace the intestines inside the abdomen. C. Place a large trauma pad over the wound. D. Use several wide cravats to loosely cover the trauma pad. Place them just tight enough to hold the abdominal contents in place.",
        "Open Abdominal Wounds": "Open abdominal wounds usually result from slashing with a knife or other sharp object and are always serious injuries. If the intestines are protruding from the abdomen (an evisceration), place the patient on his or her back with the knees bent to relax the abdominal muscles. Cover the injured area with a sterile dressing. Do not attempt to replace the intestines inside the abdomen. You can make a bandage from a large trauma pad (10 inches \u00d7 30 inches [25 cm \u00d7 76 cm]) and several cravats to cover protruding abdominal intestines. Position the trauma pad to cover the whole area of the wound. Tie two or three wide cravats loosely over the trauma pad, just tightly enough to keep it firmly in place, but not tightly enough to push the intestines back into the abdomen.\n\nEMTs and paramedics carry sterile saline (salt water) that can be poured on the dressing to keep the protruding organs moist so they do not dry out. Use only sterile saline.",
        "Treatment_19": "To treat an open abdominal wound, follow these steps:\n1. Apply a sterile dressing to the wound.\n2. Maintain the patient\u2019s body temperature.\n3. Place the patient on his or her back with the knees bent.\n4. Place the patient who is having difficulty breathing in a semireclining position.\n5. Administer oxygen if it is available and you are trained to use it.",
        "Genital Wounds": "Both male and female genitals have a rich blood supply. Injury to the genitals often results in severe bleeding. Apply direct pressure to any genital wound with a dry, sterile dressing. Direct pressure usually stops the bleeding. Although it may be embarrassing to examine the patient\u2019s genital area to determine the severity of the injury, you must do so if you suspect such injuries. The patient can experience a critical loss of blood if you do not find the injury and control the bleeding.",
        "Extremity Wounds": "To treat all open extremity wounds, apply a dry, sterile compression dressing and bandage it securely in place. Elevate the injured part to help decrease bleeding and swelling. Splint all injured extremities prior to transport because there may be an underlying fracture.",
        "Gunshot Wounds": "Some gunshot wounds are easy to miss unless you perform a thorough patient examination. Most deaths from gunshot wounds result from internal blood loss caused by damage to internal organs and major blood vessels. Because gunshot wounds are so serious, prompt and effective treatment is important. Gunshot wounds of the trunk and neck can cause spinal cord injuries. Because you cannot see the bullet\u2019s path through the body, you should treat these patients for spinal cord injuries.\n\nTo treat a patient with a gunshot wound, follow these steps:\n1. Open the airway and establish adequate ventilation and circulation.\n2. Control any external bleeding by covering wounds with sterile dressings and applying pressure with your hand or a bandage.\n3. Examine the patient thoroughly to ensure you have discovered all entrance and exit wounds.\n4. Treat for symptoms of shock by performing the following actions:\nMaintain the patient\u2019s body temperature.\nPlace the patient on his or her back and elevate the legs if indicated by local protocol.\nPlace a patient who is having difficulty breathing in a semireclining position.\nAdminister oxygen, if available.\n5.Arrange for prompt transport of the patient to an appropriate medical facility.\n6. Perform CPR if the patient\u2019s heart stops as a result of loss of blood.",
        "Bites": "Bites from animals or humans may range from minor to severe. All bites carry a high risk of causing infection. Bites from an unvaccinated or wild animal may cause rabies. Minor bites can be washed with soap and water, if they are available. Major bite wounds should be treated by controlling the bleeding and applying a suitable dressing and bandage. All patients who have been bitten by an animal or another person must be treated by a physician. In most states, EMS or hospital personnel are required to report animal bites to the local health department or a law enforcement agency. Check the laws in your local area to determine requirements.",
        "Burns": "The skin serves as a barrier that prevents foreign substances, such as bacteria, from entering the body. It also prevents the loss of body fluids. When the skin is damaged, such as by a burn, it can no longer perform these essential functions.",
        "Words of Wisdom_20": "Characteristics for burn classification include the following: Depth, Extent (amount of the body injured by the burn), Cause or type.",
        "Burn Depth": "There are three classifications of burns by depth: superficial (first-degree) burns, partial-thickness (second-degree) burns, and full-thickness (third-degree) burns. Although it is not always possible to determine the exact degree of a burn injury, it is important to understand this concept.\n\nSuperficial burns: (first-degree burns) are characterized by reddened and painful skin. The injury is confined to the outermost layers of skin, and the patient experiences minor to moderate pain. An example of a superficial burn is sunburn, which usually heals in about a week, with or without treatment.\n\nPartial-thickness burns (second-degree burns): Partial-thickness burns (second-degree burns) are somewhat deeper but do not damage the deepest layers of the skin. Blistering is present, although blisters may not form for several hours in some cases. There may be some fluid loss and moderate to severe pain because the nerve endings are damaged. Partial-thickness burns require medical treatment. They usually heal within 2 to 3 weeks.\n\nFull-thickness burns (third-degree burns): Full-thickness burns (third-degree burns) damage all layers of the skin. In some cases, the damage is deep enough to injure and destroy underlying muscles and other tissues. Pain is often absent because the nerve endings have been destroyed. Without the protection provided by the skin, patients with extensive full-thickness burns lose large quantities of body fluids and are susceptible to shock and infection.\n\nIf the patient has injuries in addition to the burn, treat the injuries before transporting the patient. For example, if a patient who has a partial-thickness burn of the arm has also fallen off a ladder and fractured both legs, splint the fractures and place the patient on a backboard, in addition to treating the burn injury.",
        "Extent of Burns": "The rule of nines is a method used to determine what percentage of the body has been burned. Although this rule is most useful for EMTs and paramedics who report information to the hospital from the field, you should be able to roughly estimate the extent of a burn. Figure 14-41 shows how the rule of nines divides the body. In an adult, the head and arms each equal 9% of the total body surface. The front and back of the trunk and each leg are equal to 18% of the total body surface. For example, if one half of the back and the entire right arm of a patient are burned, the burn involves about 18% of the total body area. The rule of nines is slightly modified for young children, but the adult percentages serve as an adequate guide.",
        "Cause or Type of Burns": "Burns are an injury to body cells caused by excess exposure to heat (thermal burns), chemicals, or electricity. They may involve a small area of the body or involve the entire body. Burns can cause minor injuries affecting only the top layers of the skin or they can be deep, involving muscles, blood vessels, and nerves. Severe burns can involve damage to all the organs and systems of the body. This section discusses the three major causes of burns: heat, chemicals, and electricity. It discusses the impact the size and severity of the burn have on the patient, as well as the care and treatment you can provide to a burn patient.",
        "Treatment_21": "Do not apply burn ointments, butter, grease, or cream to any burn!",
        "Thermal Burns": "Thermal burns are caused by heat. The first step in treating thermal burns is to cool the skin by putting out the fire. Superficial burns can be quite painful, but if there is clean, cold water available, you can place the burned area in cold water to help reduce the pain. You can also wet a clean towel with cold water and put it on superficial burns. After the burned area is cooled, cover it with a dry, sterile dressing or a large sterile cloth called a burn sheet (found in your EMR life support kit).\n\n Partial-thickness burns should be cooled if the burn area is still warm. Cooling helps reduce pain, stops the heat from further injuring the skin, and helps stop the swelling caused by partial-thickness burns.\n\nIf blisters are present, be very careful not to break the blisters. Intact skin, even if blistered, provides an excellent barrier against infection. If the blisters break, the danger of infection increases. Cover partial-thickness burns with a dry, sterile dressing or burn sheet.\n\nFull-thickness burns, if still warm, should also be cooled with water to keep the heat from damaging more skin and tissue. Cut any clothing away from the burned area, but leave any clothing that is stuck to the burn. Cover full-thickness burns with a dry, sterile dressing or burn sheet.\n\nPatients with large superficial burns or any partial-thickness or full-thickness burns must be treated for shock and transported to a hospital.",
        "Respiratory Burns": "A burn to any part of the airway is a respiratory burn. If a patient has been burned around the head and face or while in a confined space (such as in a burning house), look for the signs and symptoms of respiratory burns listed in the Signs and Symptoms box.\n\nWatch the patient carefully. Breathing problems that result from this type of burn can develop rapidly or slowly over several hours. Administer oxygen as soon as it is available and be prepared to perform CPR. If you suspect that a patient has sustained respiratory burns, arrange for prompt transport to a medical facility.",
        "Signs and Symptoms of a respiratory burn": "Signs and symptoms of a respiratory burn include the following:\nBurns around the face\nSinged nose hairs\nSoot in the mouth and nose\nDifficulty breathing\nPain while breathing\nUnconsciousness as a result of a fire",
        "Safety_23": "Chemical burns are caused by hazardous materials. In situations like this, special protective equipment may be required. Follow your local protocols for these situations.",
        "Chemical Burns": "Many strong substances can cause chemical burns to the skin, and chemicals are extremely dangerous to the eyes. These substances include strong acids such as battery acid or strong alkalis such as drain cleaners. Some chemicals are so strong or caustic that they can cause damage to the skin or eyes even if the exposure is very brief. The longer the chemical remains in contact with the skin, the more it damages the skin and underlying tissues, oftentimes resulting in superficial, partial-thickness, or full-thickness burns to the skin.\n\nThe initial treatment for chemical burns is to remove as much of the chemical as possible from the patient\u2019s skin. Brush away any dry chemical on the patient\u2019s clothes or skin, being careful not to get any on yourself. You may have to ask the patient to remove all clothing.\n\nAfter you have removed as much of the dry chemical as possible, flush the contaminated skin with abundant quantities of water. Use water from a garden hose, a shower in the home or factory, or even the booster hose of a fire engine. It is essential that the chemical be washed off the skin quickly to avoid further injury. Flush the affected area of the body for at least 10 minutes, then cover the burned area with a dry, sterile dressing or a burn sheet and arrange for prompt transport to an appropriate medical facility.\n\nChemical burns to the eyes cause extreme pain and severe injury. Gently flush the affected eye or eyes with water for at least 20 minutes. Hold the eye open to allow water to flow over its entire surface. Direct the water from the inner corner of the eye to the outward edge of the eye to avoid contaminating the unaffected eye. You may have to put the patient\u2019s face under a shower, garden hose, or faucet so the water flows across the patient\u2019s entire face. Continue flushing the eyes while the patient is being transported. After flushing the eyes for 20 minutes, loosely cover the injured eye or eyes with gauze bandages and arrange for prompt transport to an appropriate medical facility. All chemical burns should be examined by a physician.",
        "Electrical Burns": "Electrical burns can cause severe injuries or even death, but they leave little evidence of injury on the outside of the body. These burns are caused by an electrical current that enters the body at one point (for example, the hand that touches the live electrical wire), travels through the body tissues and organs, and exits from the body at the point of ground contact.\n\nA. An entrance wound is often small. B. An exit wound can be extensive and deep. \n\nElectricity causes major internal damage, rather than external damage. A strong electrical current can actually \u201ccook\u201d muscles, nerves, blood vessels, and internal organs, resulting in major damage. Patients who have been subjected to a strong electrical current can also experience irregularities of cardiac rhythm or even full cardiac arrest and death. Children often sustain electrical burns by chewing on an electrical cord or by pushing something into an outlet. Although the burn may not look serious at first, it is often quite severe because of underlying tissue injury.\n\nPersons who have been hit or nearly hit by lightning frequently sustain electrical burns. Treat these patients as you would electrical burn patients. Evaluate them carefully because they may also experience cardiac arrest. Arrange for prompt transport to an appropriate medical facility.\n\nBefore you touch or treat a person who has sustained an electrical burn, be certain the patient is not still in contact with the electrical power source caused the burn. If the patient is still in contact with the power source, anyone who touches him or her may be electrocuted. If the patient is touching a live power source, your first act must be to unplug, disconnect, or turn off the power. If you cannot do this alone, call for assistance from the power company or from a qualified rescue squad or fire department. Do not touch the patient without unplugging, disconnecting, or turning off the power first.\n\nIf a power line falls on top of a motor vehicle, the people inside the vehicle must be told to stay inside until qualified personnel can remove the power line or turn the power off. After ensuring that the power has been disconnected, examine each electrical burn patient carefully, assess the ABCs, and treat the patient for visible, external burns. Cover these external burns with a dry, sterile dressing and arrange for prompt transport to an appropriate medical facility. Monitor the airway, breathing, and circulation of electrical burn patients closely, and arrange to have these patients transported promptly to an appropriate medical facility for further treatment.",
        "Safety_24": "Avoid direct or indirect contact with live electrical wires. Direct contact occurs when you touch a live electrical wire. Indirect contact occurs",
        "Multi-System Trauma": "Multi-system trauma is an injury that affects more than one body system. The injuries in multi-system trauma can occur in one part of the body but involve different body systems. For example, an unrestrained patient who hits the steering wheel in a motor vehicle crash can sustain trauma to the chest. This trauma could result in injuries to both the heart (the circulatory system) and to the lungs (the respiratory system). Another patient in a vehicle crash might have injuries to different parts of body, for example, to the abdomen and to the head. Both of these patients have sustained multi-system trauma. As an EMR, you are not expected to diagnose a patient\u2019s injuries. However, it is important to remember that several body systems may be injured in situations that involve significant trauma. As you assess your patients, be alert for signs and symptoms of injury to each part of the body.",
        "Prep Kit-Ready for Review": "This chapter covers the knowledge and skills you need to treat patients experiencing shock, bleeding, and soft-tissue injuries.\n\nMaintain standard precautions to prevent contact with the patient\u2019s body fluids.\n\nThe three parts of the circulatory system are the pump (heart), the pipes (arteries, veins, and capillaries), and the fluid (blood cells and other blood components).\n\nShock is a state of collapse of the cardiovascular system that results in inadequate delivery of blood to the organs. The three primary causes of shock are pump failure, pipe failure, and fluid loss. The general treatment for shock is positioning the patient correctly, maintaining the patient\u2019s ABCs, and treating the cause of shock, if possible.\n\nThere are three types of external blood loss: capillary (blood oozes out), venous (bleeds at a steady flow), and arterial (blood spurts or surges). Most external bleeding can be controlled by applying direct pressure to the wound.\n\nA wound is an injury caused by any physical means that leads to damage of a body part. Wounds are classified as closed (skin remains intact) or open (skin is disrupted). Open wounds are classified as abrasions, punctures, lacerations, and avulsions or amputations.\n\nControl bleeding by covering an open wound with a dry, clean, or sterile dressing and apply pressure to the dressing with your hand. Additional ways to control bleeding include elevating an extremity, applying a tourniquet, and using pressure points.\n\nThere are three classifications of burns by depth: superficial (first-degree) burns, partial-thickness (second-degree) burns, and full-thickness (third-degree) burns. Burns may be caused by heat, chemicals, or electricity.\n\nBy learning to recognize and provide initial emergency treatment for patients experiencing shock, bleeding, and soft-tissue injuries, you will be able to provide physical and emotional assistance to these patients in their time of need. At times, your prompt recognition and treatment will make a real difference in the outcome.\n\nInjuries that affect more than one body system are called multi-system trauma. Multi-system trauma may be a result of an injury to one part of the body or it can be caused by injuries to different parts of the body.",
        "Vital Vocabulary": "abrasion: Loss or damage of skin as a result of a body part being rubbed or scraped across a rough or hard surface., anaphylactic shock: Shock caused by an extreme allergic reaction to certain foods, medications, or insect bites and stings., arterial bleeding: Serious bleeding from an artery in which blood frequently pulses or spurts from an open wound., atria: The two upper chambers of the heart., avulsion: An injury in which a piece of skin is torn completely loose or is left hanging as a flap., blood pressure: The pressure of the circulating blood against the walls of the arteries., brachial artery pressure point: Pressure point located in the arm between the elbow and the shoulder; also used in taking blood pressure and for checking the pulse in infants., bruise: Injury caused by a blunt object striking the body and crushing the tissue beneath the skin. Also called a contusion., capillary bleeding: Bleeding from the capillaries in which blood oozes from the open wound., cardiogenic shock: Shock resulting from inadequate functioning of the heart., chemical burns: Burns that occur when any toxic substance comes in contact with the skin. Most chemical burns are caused by strong acids or alkalis., closed wound: Injury in which soft-tissue damage occurs beneath the skin but there is no break in the surface of the skin., congestive heart failure (CHF): Heart disease characterized by breathlessness, fluid retention in the lungs, and generalized swelling of the body., cravat: A triangular swathe of cloth used to hold a body part splinted against the body., dressing: Any of various materials placed directly on a wound to control bleeding and prevent further contamination., electrical burns: Burns caused by contact with high- or low-voltage electricity. Electrical burns have an entrance and an exit wound., entrance wound: Point where an object such as a bullet enters the body., exit wound: Point where an object such as a bullet passes out of the body., femoral artery pressure point: Pressure point located in the groin, in the middle of the bottom crease of the groin, between the groin and the upper thigh., full-thickness burns: Burns that extend through the skin and into the underlying tissues; the most serious class of burns., gunshot wound: A puncture wound caused by a bullet or shotgun pellets., hemorrhage: Excessive bleeding., hemostatic agent: A chemical compound that slows or stops bleeding by assisting with clot formation., immobilize: To reduce or prevent movement of a limb, usually by splinting., impaled object: An object such as a knife, splinter of wood, or glass that penetrates the skin and remains in the body., intravenous (IV) fluids: Fluids other than blood or blood products infused into the vascular system to maintain an adequate circulatory blood volume., laceration: An irregular cut or tear through the skin., multi-system trauma: An injury that affects more than one body system., occlusive dressing: An airtight dressing or bandage for a wound., open wound: Injury that breaks open the skin or mucous membrane., partial-thickness burns: Burns in which the outer layers of skin are burned; these burns are characterized by blister formation., pneumatic antishock garments (PASGs): Trouser-like devices placed around a shock victim\u2019s legs and abdomen and inflated with air., pressure points: Points where a blood vessel lies near a bone; pressure can be applied to these points to help control bleeding., psychogenic shock: Commonly known as fainting; caused by a temporary reduction in blood supply to the brain., puncture: A wound resulting from a bullet, knife, ice pick, splinter, or any other pointed object., rabies: An acute viral infection of the central nervous system transmitted by the bite of an infected animal., respiratory burn: Burn to the respiratory system resulting from inhaling superheated air., road rash: An abrasion caused by sliding on pavement. Usually seen after motorcycle or bicycle accidents., rule of nines: Used to calculate the amount of body surface burned; the body is divided into sections, each of which constitutes approximately 9% or 18% of the total body surface area., saline: Salt water., shock: A state of collapse of the cardiovascular system; the state of inadequate delivery of blood to the organs of the body., splint: A means of immobilizing an injured part by using a rigid or soft support., spontaneous nosebleed: A nosebleed with no apparent cause., superficial burns: Burns in which only the superficial part of the skin has been injured; an example is a sunburn., thermal burns: Burn caused by heat; the most common type of burn., venous bleeding: External bleeding from a vein, characterized by steady flow; the bleeding may be profuse and life threatening., ventricles: The two lower chambers of the heart."
    },
    {
        "Sager Traction Splint": "The Sager Traction Splint is used for suspected femur fractures not involving the hip or knee and with no RTC criteria. It is typically applied on-scene after completing a secondary survey. The splint involves assessing the injured leg by checking for distal pulses, performing motor-sensory checks, and determining the exact location and extent of injury. Analgesia is administered as appropriate per Entonox protocols. The splint is adjusted to ensure the short side of the saddle hinge is down, and the saddle is nestled against the injured leg. A helper stabilizes the splint, and small thigh straps are applied. Ankle harnesses are placed above the malleoli, and traction is applied at 10% body weight, with maximum limits of 15 lbs per limb for adults, 5 lbs for open fractures, 5 lbs for pediatric patients, and 30 lbs for bilateral fractures (15 lbs per leg). Adequate padding is ensured, and the splint is secured with three straps around the splint above and below the injury, followed by securing the thigh strap and then the other two straps using a figure-eight strap. Reassessment includes rechecking all splint straps and the traction gauge, ensuring the leg is in line with the body, same length as the other leg, rechecking the presence or absence of distal pulses, and ensuring no movement or aggravation of the injured limb."
    },
    {
        "T-POD/Pelvic Binder Application Indications": "The T-POD/Pelvic Binder should be applied when there is a high suspicion of a pelvic fracture, accompanied by any of the following: a heart rate above 100 bpm or systolic blood pressure below 90 mmHg indicating hemodynamic instability, pelvic pain during examination, pelvic instability, decreased level of consciousness (LOC), or significant injuries that distract from a pelvic exam.",
        "T-POD/Pelvic Binder Application Contraindications": "Contraindications include suspected hip dislocation or neck-of-femur fracture, and simple falls such as those from a standing height.",
        "T-POD/Pelvic Binder Application Procedure": "Ensure the T-POD makes direct contact with the skin (cut and expose) if possible. Slide the T-POD belt under the supine patient and into position under the pelvis. Align the center of the T-POD belt with the greater trochanter (top of hips). Trim the T-POD belt so there is a 15-20 cm (6-8 inch) gap centered over the pubic symphysis. Apply the Velcro tension straps, slowly drawing tension to create simultaneous circumferential compression until the gap is closed. The compression should be snug enough to provide stability but loose enough to allow insertion of two fingers between the belt and waist. Secure the belts to ensure constant pressure without accidental release. Document the application of the T-POD, including date and time of application. If release is required or occurs accidentally, note the time of this event.",
        "Release of T-POD": "If release is required or occurs accidentally, document the time of this event."
    },
    {
        "National EMS Education Standard Competencies": "Medicine\nApplies fundamental knowledge to provide basic emergency care and transportation based on assessment findings for an acutely ill patient. Diseases of the Eyes, Ears, Nose, and Throat\nRecognition and management of\nNosebleed Trauma\nApplies fundamental knowledge to provide basic emergency care and transportation based on assessment findings for an acutely injured patient. Head, Facial, Neck, and Spine Trauma\nRecognition and management of\nLife threats\nPathophysiology, assessment, and management of\nPenetrating neck trauma\nLaryngotracheal injuries Head, Facial, Neck, and Spine Trauma (cont\u2019d)\nPathophysiology, assessment, and management of (cont\u2019d)\nFacial fractures\nForeign bodies in the eyes\nDental trauma",
        "Introduction Face and neck are vulnerable to injury.": "Relatively unprotected positions on body\nSoft-tissue injuries and fractures are common and vary in severity.\nSome injuries are life-threatening.\nPenetrating trauma to the neck may cause severe bleeding.\nOpen injury may result in an air embolism.",
        "The Head Cranium": "Contains the brain\nMost posterior portion is called the occiput.\nLateral portions on each side are called temples or temporal regions.\nForehead is called the frontal region.\nAnterior to the ear, in the temporal region, you can feel the pulse of the superficial temporal artery.",
        "Six major bones include:": "Nasal bone\nTwo zygomas\nTwo maxillae\nMandible FIGURE 28-1 The face is composed of six bones: the\nnasal bone, two maxillae, two zygomas, and the mandible \u00a9 Jones & Bartlett Learning. The orbit of the eye is composed of:\nLower edge of the frontal bone of the skull\nZygoma\nMaxilla\nNasal bone\nProtects the eye from injury Only the proximal third of the nose is formed by bone.\nThe remaining two thirds are composed of cartilage. The exposed portion of the ear is composed entirely of cartilage covered by skin.\nPinna\nTragus\nSuperficial temporal artery FIGURE 28-2 Specific landmarks of the head and neck\ninclude the pinna, the mandible, the occiput, the seventh\ncervical vertebra, and the temporomandibular joint. \u00a9 Jones & Bartlett Learning. About 1 inch posterior to the external opening of the ear is the mastoid process.\nThe mandible forms the jaw and chin.",
        "Contains many important structures": "Supported by the cervical spine\nThe upper part of the esophagus and the trachea lie in the midline of the neck.\nThe carotid arteries are found on either side of the trachea. The larynx\nAdam\u2019s apple is located in the center of the neck.\nOther portion of the larynx is the cricoid cartilage. FIGURE 28-3 Important landmarks in the neck include the\ncricoid cartilage, the thyroid cartilage, the carotid arteries,\nthe cricothyroid membrane, and the sternocleidomastoid\nmuscles. \u00a9 Jones & Bartlett Learning The larynx (cont\u2019d)\nThe cricothyroid membrane lies between the thyroid cartilage and the cricoid cartilage. FIGURE 28-4 The larynx \u00a9 Jones & Bartlett Learning The trachea\nBelow the larynx \nConnects the oropharynx and larynx with the main passages of the lungs\nSternocleidomastoid muscles\nOriginate from the mastoid process\nAllow movement of the head",
        "Globe-shaped, approximately 1 inch in diameter": "Located within a bony socket in the skull called the orbit\nComposed of adjacent bones of the face and skull\nProtects over 80% of the eyeball \u00a9 Jones & Bartlett Learning FIGURE 28-5 The major structures of the eye. Clear, jellylike fluid near the back of the eye is called vitreous humor.\nIn front of the lens is a fluid called the aqueous humor, which can leak out in penetrating injuries. The conjunctiva is the membrane that covers the eye.\nThe lacrimal glands produce fluid to keep the eye moist. \u00a9 Jones & Bartlett Learning FIGURE 28-6 The lacrimal system consists of tear glands and ducts. Tears act as a lubricant and keep the front of the eye from drying out. The sclera is the white, fibrous tissue that helps maintain the globular shape.\nOn the front of the eye, the sclera is replaced by a clear, transparent membrane called the cornea.\nAllows light to enter the eye\nThe iris is a circular muscle behind the cornea. The pupil is the opening in the center of the iris.\nAllows light to move to the back of the eye\nAnisocoria is a condition in which a person is born with different-sized pupils.\nThe lens lies behind the iris.\nFocuses images on the retina at the back of the globe The retina contains nerve endings.\nRespond to light by transmitting nerve impulses through the optic nerve to the brain\nThe retina is nourished by a layer of blood vessels called the choroid.\nRetinal detachment causes blindness.",
        "Injuries of the Face and Neck": "Can often lead to partial or complete obstruction of the upper airway\nSeveral factors may contribute.\nBlood clots from heavy facial bleeding\nDirect injuries to the nose and mouth, larynx, and trachea\nDislodgment of teeth or dentures into the throat Several factors (cont\u2019d)\nSwelling that accompanies direct and indirect injury\nAirway may be affected when the patient\u2019s head is turned to the side\nPossible injuries to the brain and/or cervical spine",
        "Soft-Tissue Injuries Face and neck are extremely vascular.": "Swelling may be more severe.\nSkin and tissues in these areas have a rich blood supply.\nA blunt injury can cause a hematoma. FIGURE 28-7 Facial hematoma. \u00a9 Willowpix/E+/Getty Images.",
        "Dental Injuries": "Mandible fractures are common.\nMost injuries are the result of vehicle collisions and assaults.\nSigns of mandible fractures include:\nMisalignment of the teeth\nNumbness of the chin\nAn inability to open the mouth Maxillary fractures are usually found after blunt-force, high-energy impacts.\nSigns of maxillary fractures include:\nMassive facial swelling\nInstability of the facial bones\nMisalignment of teeth\nFractured and avulsed teeth are common following facial trauma. Can be traumatic to the patient\nBleeding will occur whenever a tooth is violently displaced from its socket.\nApply direct pressure to stop the bleeding.\nPerform suctioning if needed.\nCracked or loose teeth are possible airway obstructions. Save and transport an avulsed tooth.\nHandle it by the crown rather than the root.\nPlace the tooth in tooth storage solution, cold milk, or sterile saline.\nNotify the hospital.\nReimplantation is recommended within 20 minutes to 1 hour after the trauma.",
        "Scene Size-up": "Scene safety\nObserve for hazards and threats.\nAssess for potential violence and environmental hazards.\nEye protection and face mask are standard.\nDetermine the number of patients. Mechanism of injury/nature of illness\nAssess the scene.\nCommon MOI for face and neck injuries:\nMotor vehicle collisions\nSports\nFalls\nPenetrating trauma\nBlunt trauma",
        "Primary Assessment": "Focuses on identifying and managing life-threatening concerns\nThreats to XABCs must be treated immediately. \nWhen there is life-threatening external hemorrhage, it should be addressed before airway and breathing. Form a general impression.\nLook for important indicators about the seriousness of the patient\u2019s condition.\nInjuries may be very obvious or hidden.\nControl blood loss with direct pressure.\nConsider the need for manual spinal stabilization.\nCheck for responsiveness using the AVPU scale. Airway and breathing\nEnsure a clear and patent airway.\nIf the patient is unresponsive or has significantly altered LOC, consider a properly sized oropharyngeal airway.\nQuickly assess for adequacy of breathing. \nPalpate the chest wall for DCAP-BTLS.\nSplinting or otherwise restricting chest wall motion is contraindicated. Circulation\nQuickly assess pulse rate and quality.\nDetermine skin condition, color, and temperature.\nCheck capillary refill time.\nSignificant bleeding is an immediate life threat. Transport decision\nConsider quickly transporting patients with airway or breathing problems or with significant bleeding.\nConsider ALS backup.\nA patient with internal bleeding must be transported quickly for treatment by a physician. Transport decision (cont\u2019d)\nSigns of hypoperfusion imply the need for rapid transport.\nThe patient who has a significant MOI but whose condition appears stable should be transported promptly.\nAny significant blow to the face or throat should increase your suspicion of spinal or brain injury.",
        "History Taking Investigate the chief complaint.": "Obtain a medical history.\nBe alert for injury-specific signs and symptoms.\nBe aware of pertinent negatives.\nGather a SAMPLE history from the patient, or from friends and family.",
        "Secondary Assessment": "Physical examinations\nIf multiple systems have been affected, start with an assessment of the entire body, looking for DCAP-BTLS.\nDo not delay transport to complete a thorough physical examination.\nIn a responsive patient with an isolated injury with limited MOI, consider focusing on the isolated injury, the patient\u2019s chief complaint, and the body region affected. Physical examinations (cont\u2019d)\nEnsure that control of bleeding is maintained and note injury location.\nInspect the open wound for any foreign matter and stabilize impaled objects.\nUse both your eyes and your hands.\nAssess all underlying systems. Physical examinations (cont\u2019d)\nWhen evaluating the eyes, start with the outer aspect and work toward the pupils.\nExamine the eye for any obvious foreign matter. \nVisual acuity is a vital sign of the eye. \nLook for discoloration, bleeding, redness, eye symmetry, and pupil size and reaction to light. Vital signs\nAssess vital signs to obtain a baseline.\nYou must be concerned with visible bleeding and unseen bleeding inside a body cavity.\nWith facial and throat injuries, baseline information is very important.\nUse appropriate monitoring devices.",
        "Reassessment": "Repeat the primary assessment.\nReassess vital signs and the chief complaint.\nReassess the patient\u2019s condition at least every 5 minutes.\nInterventions\nProvide complete spinal immobilization if necessary. Interventions (cont\u2019d)\nMaintain an open airway, be prepared to suction, and consider an oropharyngeal airway.\nWhenever you suspect significant bleeding, provide high-flow oxygen.\nControl significant visible bleeding. Interventions (cont\u2019d)\nIf the patient has signs of hypoperfusion, treat aggressively for shock and provide rapid transport.\nCommunication and documentation\nInclude a description of the MOI and the position in which you found the patient.",
        "Emergency Medical Care": "Treat soft-tissue injuries to the face and neck the same as soft-tissue injuries elsewhere on the body.\nAssess XABCs and life threats first.\nFollow standard precautions. \nIn the absence of life-threatening bleeding, first open and clear the airway.\nAvoid moving the neck in patients with suspected cervical spine injuries. Control bleeding by applying direct manual pressure with a dry, sterile dressing.\nUse roller gauze, wrapped around the head, to hold a pressure dressing in place.\nDo not apply excessive pressure if an underlying skull fracture is suspected. Cover exposed brain, eye, or other structures with a moist, sterile dressing.\nApply ice locally to injuries that do not break the skin.\nFor soft-tissue injuries around the mouth, check for bleeding inside the mouth. Physicians can sometimes graft a piece of avulsed skin back into position.\nIf you find portions of avulsed skin:\nWrap in a sterile dressing.\nPlace in a plastic bag.\nKeep cool, but do not place directly on ice.\nLabel and deliver to the emergency department. If the avulsed skin is still attached in a loose flap:\nPlace the flap in position as close to normal as possible.\nHold in place with a dry, sterile dressing.",
        "Injuries of the Eyes": "Eye injuries are common, particularly in sports.\nCan produce lifelong complications, including blindness\nAfter an injury, pupil reaction or shape and eye movement are disturbed. Treatment starts with a thorough examination.\nAlways use standard precautions.\nTake care not to aggravate any problems.\nLook for abnormalities or conditions that may suggest the nature of the injury. Foreign objects\nThe orbit protects the eye from the penetration of large objects.\nEven a small object may produce severe irritation.\nIrrigation with a sterile saline solution will frequently flush away loose particles. Foreign objects (cont\u2019d)\nAlways flush from the nose side of the eye toward the outside to avoid flushing material into the other eye. \u00a9 American Academy of Orthopaedic Surgeons Foreign objects (cont\u2019d)\nA foreign body will leave a small abrasion on the conjunctiva.\nGentle irrigation may not wash out foreign bodies stuck to the cornea or lying under the upper eyelid. Foreign objects (cont\u2019d)\nForeign bodies may be impaled in the eye.\nBandage the object in place to support it.\nCover the eye with a moist, sterile dressing.\nSurround the object with a doughnut-shaped collar.\nWhen you see or suspect an impaled object(s) in the eye, bandage both eyes with soft, bulky dressings to prevent further injury. Burns of the eye\nStop the burn and prevent further damage.\nChemical burns\nUsually caused by acid or alkaline solutions\nFlush the eye with water or saline.\nDirect the greatest amount of irrigating solution or water into the eye as gently as possible. FIGURE 28-17 The following are four ways to effectively irrigate the eye. A. Nasal cannula. B. Shower. C. Bottle. D. Basin.\nRemember, you must protect the uninjured eye from the irrigating solution to prevent exposure of the unaffected eye to the substance. A, C: \u00a9 American Academy of Orthopaedic Surgeons; B, D: \u00a9 Jones & Bartlett Learning. Chemical burns (cont\u2019d)\nYou may have to force the lids open.\nFlush from the inner to outside corner. \nIf the burn was caused by an alkali or a strong acid, irrigate continuously for at least 20 minutes.\nAfter irrigation, apply a clean, dry dressing to cover the eye and transport. Thermal burns\nDuring a fire, the eyes will close to protect from heat, and the eyelids will burn.\nTransport promptly without further examination.\nCover both eyes with a sterile dressing moistened with sterile saline.\nApply eye shields over the dressing. Light burns\nInfrared rays, eclipse light, and laser beams all can cause significant damage.\nRetinal injuries caused by exposure to light are generally not painful but may result in permanent damage.\nSevere conjunctivitis usually develops with redness, swelling, and excessive tears. Lacerations\nRequire very careful repair to restore appearance and function\nBleeding may be heavy, but it usually can be controlled with gentle, manual pressure.\nIf there is a laceration of the globe itself, apply no pressure to the eye. Lacerations (cont\u2019d)\nOn rare occasions, the eyeball may be displaced from its socket.\nDo not attempt to reposition it.\nCover the eye and stabilize it with a moist sterile dressing.\nCover both eyes to prevent further injury.\nHave the patient lie supine. Blunt trauma\nHyphema obscures all or part of the iris.\nAn orbit fracture is a fracture of the bones that form the eye floor and support the globe.\nRetinal detachment is often seen in sports. Eye injuries following head injury\nSigns and symptoms of a possible head injury:\nOne pupil larger than the other\nEyes not moving together\nFailure of the eyes to follow your finger\nBleeding under the conjunctiva\nProtrusion or bulging of one eye Blast injuries\nSigns and symptoms range from severe pain and loss of vision to foreign bodies within the globe.\nIf there is a foreign body within the globe, do not remove it.\nIf only one eye is injured, follow local protocol.\nIf the patient has severe swelling, do not force the eyelid open to examine it. Contact lenses and artificial eyes\nDo not attempt to remove contact lenses unless there is a chemical burn.\nTo remove a hard contact lens, use a small suction cup.\nTo remove soft contact lenses, place one or two drops of saline in the eye, pinch the lens between your thumb and index finger, and lift. FIGURE 28-26 Removing contact lenses should be\nlimited to patients with chemical burn injuries to the eye.\nA. To remove hard contact lenses, use a specialized\nsuction cup moistened with sterile saline solution. B. To\nremove soft contact lenses, instill one or two drops of\nsaline or irrigating solution. C. Next, pinch off the lens with\nyour gloved thumb and index finger A, B, C: \u00a9 Jones & Bartlett Learning.",
        "Injuries of the Nose": "Nosebleeds (epistaxis) are a common problem.\nOne of the most common causes is digital trauma.\nAnterior nosebleeds usually originate from the area of the septum and bleed slowly.\nPosterior nosebleeds are usually more severe and often cause blood to drain into the throat. Blunt injuries to the nose may be associated with fractures and soft-tissue injuries of the face, head injuries, and/or injuries to the cervical spine. Assess the nose structures for injury. FIGURE 28-27 The nose has two chambers, divided by\nthe septum. Each chamber is composed of layers of bone\ncalled turbinates. Above the nose are the frontal sinuses\nand, on either side, the orbits of the eyes. \u00a9 Jones & Bartlett Learning. Patients with severe nasal injury may also have cervical spine injury.\nCerebrospinal fluid (CSF) may escape down through the nose following a fracture at the base of the skull.\nControl bleeding by applying a sterile dressing.",
        "Injuries of the Ear": "Divided into three parts:\nExternal ear\nMiddle ear\nInner ear FIGURE 28-29 The ear has three principal parts: the external, or outer, ear, composed of the pinna, external auditory canal, and tympanic membrane; the middle ear, including the hammer, anvil, and stirrup; and the inner ear, composed of bony chambers filled with fluid. \u00a9 Jones & Bartlett Learning. Ears are often injured, but they do not usually bleed very much.\nIn case of an ear avulsion, wrap the avulsed part in a moist, sterile dressing and put it in a plastic bag.\nTympanic membrane rupture\nPatients will report severe ear pain, difficulty hearing, or ringing in the affected ear. Tympanic membrane rupture (cont\u2019d)\nMay be caused by insertion of objects too far into the ear. \nChildren place foreign bodies in the external auditory canal.\nClear fluid coming from the ear may indicate a skull fracture.",
        "Typically result from blunt impact": "Assume a direct blow to the mouth or nose has caused a facial fracture.\nOther clues include:\nBleeding in the mouth\nInability to swallow or talk\nAbsent or loose teeth\nLoose or movable bone fragments Facial fractures alone are not acute emergencies unless there is serious bleeding.\nPlastic surgeons can repair the damage to the face and mouth if the injuries are treated within 7 to 10 days.\nSwelling can be extreme within the first 24 hours after injury.",
        "Injuries of the Cheek You may encounter an object impaled in the patient\u2019s cheek.": "If you are unable to control the bleeding, consider removing the object.\nProvide direct pressure on the inside and outside of the cheek.\nThe amount of bandaging should not occlude the mouth.",
        "Injuries of the Neck": "The neck contains many structures vulnerable to injury by blunt trauma.\nUpper airway\t\nEsophagus\nCarotid arteries and jugular veins\nThyroid cartilage (Adam\u2019s apple)\nCricoid cartilage\nUpper part of the trachea Blunt injuries\nAny crushing injury of the upper part of the neck is likely to involve the larynx or trachea.\nCan lead to loss of voice, difficulty swallowing, severe and sometimes fatal airway obstruction, and leakage of air into soft tissues of the neck Blunt injuries (cont\u2019d)\nSubcutaneous emphysema is a characteristic crackling sensation produced by the presence of air.\nComplete airway obstruction can develop rapidly.\nConsider ALS support early. \nConsider spinal motion restriction. Penetrating injuries\nCan cause profuse bleeding from laceration of the great vessels in the neck\nInjuries to the carotid and jugular veins can cause the body to bleed out (exsanguination).\nInjuries to these large vessels may also allow air to enter the circulatory system, which can lead to air embolism and cardiac arrest.\nDirect pressure will control most bleeding.",
        "Laryngeal Injuries": "Blunt force trauma to the larynx can occur when:\nUnrestrained driver strikes steering wheel.\nSnowmobile rider strikes a clothesline.\nThe larynx becomes crushed against the cervical spine, resulting in soft-tissue injury, fractures, and/or separation of the fascia. Penetrating or impaled objects in the larynx should not be removed unless they interfere with CPR.\nStabilize all impaled objects if they are not obstructing the airway. Signs and symptoms of larynx injuries:\nRespiratory distress\nHoarseness\nPain\nDifficulty swallowing (dysphagia)\nCyanosis\nPale skin\nSputum in the wound Signs and symptoms (cont\u2019d)\nSubcutaneous emphysema\nBruising on the neck\nHematoma\nBleeding\nTo manage a laryngeal injury: \nProvide oxygen and ventilation. \nApply cervical immobilization but avoid rigid collars."
    },
    {
        "National EMS Education Standard Competencies": "Trauma\nApplies fundamental knowledge to provide basic emergency care and transportation based on assessment findings for an acutely injured patient. Trauma Overview\nPathophysiology, assessment, and management of the trauma patient\nTrauma scoring\nRapid transport and destination issues\nTransport mode Multisystem Trauma\nRecognition and management of\nMultisystem trauma\nPathophysiology, assessment, and management of\nMultisystem trauma\nBlast injuries",
        "Introduction": "For people younger than age 44, traumatic injuries are the leading cause of death in the United States.\nTraumatic emergencies occur as result of physical forces applied to the body.\nMedical emergencies occur from an illness or condition not caused by an outside force. Index of suspicion is your awareness and concern for potentially serious underlying and unseen injuries.",
        "Energy and Trauma": "Traumatic injury occurs when the body\u2019s tissues are exposed to energy levels beyond their tolerance.\nThe mechanism of injury is the way traumatic injuries occur.\nDescribes the forces acting on the body that cause injury Three concepts of energy\nPotential energy\nKinetic energy\nEnergy of work\nEnergy can be neither created nor destroyed; it can only be converted or transformed. Work is force acting over a distance.\nForces that bend, pull, or compress tissues beyond their inherent limits result in the work that causes injury. Kinetic energy is the energy of a moving object.\nKE = \u00bd mass x velocity2\nPotential energy is the product of mass, force of gravity, and height.\nMostly associated with the energy of falling objects",
        "Mechanism of Injury Profiles": "Different MOIs produce many types of injuries.\nNonsignificant injuries \nInjury to an isolated body part\nFall without the loss of consciousness Significant injuries:\nInjury to more than one body system (multisystem trauma)\nFalls from heights\nMotor vehicle and motorcycle crashes\nCar versus pedestrian (or bicycle)\nGunshot wounds\nStabbings",
        "Blunt and Penetrating Trauma Blunt trauma is the result of force to the body that causes injury without penetrating the soft tissues.": "Penetrating trauma causes injury by objects that pierce and penetrate the surface of the body.\nEither type may occur from a variety of MOIs.",
        "Blunt Trauma Results from an object making contact with the body": "Motor vehicle crashes and falls are the most common MOIs.\nBe alert to skin discoloration and pain.\nMaintain a high index of suspicion for hidden injuries.",
        "Vehicular Crashes": "A crash consists of three collisions.\nCar against another car, tree, or object\nBy assessing the vehicle, you can often determine the MOI. FIGURE 25-3 The first collision in a typical impact is that of the vehicle against another object (in this case, a utility pole). The appearance of the vehicle can provide you with critical information about the severity of the crash. The greater the damage to the vehicle, the greater the energy that was involved. \u00a9 Rocketegg/iStock /Getty Images Plus/Getty Images. Passenger against the interior of the car\nCommon passenger injuries include lower extremity fractures, flail chest, and head trauma. FIGURE 25-4 The second collision in a typical impact is that of the passenger against the interior of the car. The appearance of the interior of the car can provide you with information about the severity of the patient\u2019s injuries Courtesy of Rhonda Hunt. Passenger\u2019s internal organs against solid structures of the body\nInternal injuries may not be as obvious as external injuries but are often the most life threatening. FIGURE 25-6 The third collision in a typical impact is that of the passenger\u2019s internal organs against the solid structures of the body. A coup-contrecoup injury occurs when the brain continues its forward motion and strikes the inside of the skull (the coup), resulting in a compression injury to the anterior portion of the brain and a tension injury (stretching) of the posterior portion (the contrecoup). \u00a9 Jones & Bartlett Learning. Significant MOIs include the following findings:\nDeath of an occupant in the vehicle\nSevere deformity of vehicle or intrusion into vehicle\nSevere damage from the rear\t\nCrashes in which rotation is involved\nEjection from the vehicle",
        "Frontal Crashes": "Evaluate supplemental restraint system\nDetermine whether the passenger was restrained and whether the airbags deployed.\nSeat belts and airbags are effective in preventing a second collision inside the motor vehicle.\nAirbags decrease the severity of deceleration injuries and decrease injury to the chest, face, and head. Despite airbags, suspect injuries to:\nExtremities (resulting from the second collision)\nInternal organs (resulting from the third collision) Children shorter than 4\u2019 9\" should ride in the rear seat.\nRemember that if the airbag did not inflate during the accident, it may deploy during extrication. Remember that supplemental restraint systems can cause harm whether they are used properly or improperly. FIGURE 25-7 Injuries can result if the seat belt is worn too high or too low across the waist. Although less common, injuries can also result from seat belts worn in the correct position across the torso. Courtesy of ED, Royal North Shore Hospital/NSW Institute of Trauma & Injury. Look for contact points between the patient and the vehicle as you perform a simple, quick evaluation of the interior of the vehicle.",
        "Rear-End Crashes": "Known to cause whiplash-type injuries\nParticularly in absence of a headrest FIGURE 25-10 Rear-end impacts often cause whiplash\ninjuries, particularly when the head and/or neck is not\nrestrained by a headrest. \u00a9 Crystalcraig/Dreamstime.com. As the body is propelled forward, the head and neck are left behind.\nAcceleration-type injury to the brain is possible.",
        "Lateral Crashes": "Side impacts\nVery common cause of death associated with motor vehicle crashes FIGURE 25-11 In a lateral crash, the car is typically struck\nabove its center of gravity and begins to rock away from\nthe side of impact. This causes a type of lateral whiplash\nin which the passenger\u2019s shoulders and head whip toward the intruding vehicle. A vehicle struck from the side is usually struck above its center of gravity.\nBegins to rock away from the side of impact\nResults in the passenger sustaining a lateral whiplash injury If substantial intrusion into the passenger compartment, suspect:\nLateral chest and abdomen injuries on the side of the impact\nPossible fractures of the lower extremities, pelvis, and ribs\nOrgan damage from the third collision",
        "Rollover Crashes Large trucks and sport utility vehicles are prone to rollovers.": "Injuries depend on whether the passenger was restrained.\nMost common life-threatening event is ejection or partial ejection of the passenger from the vehicle.",
        "Rotational Crashes Spins are conceptually similar to rollovers.": "Rotation of the vehicle provides opportunities for the vehicle to strike objects such as utility poles",
        "Car Versus Pedestrian": "Injuries are often graphic and apparent.\nCan also be serious unseen injuries\nYou should determine:\nSpeed of the vehicle\nWhether the patient was thrown through the air\nSurface the patient landed on\nWhether the patient was struck and pulled under the vehicle Evaluate the vehicle that struck the patient for structural damage.\nALS backup should be summoned for any patients who have sustained a significant MOI.",
        "Car Versus Bicycle": "Evaluate like you would for a car-versus-pedestrian collision.\nEvaluate the damage to and position of the bicycle.\nIf the patient was wearing a helmet, inspect it for damage. FIGURE 25-13 If the patient\u2019s bike helmet is damaged, suspect head and spine injuries \u00a9 Robert Byron/Dreamstime.com. Presume that the patient has sustained an injury to the spinal column, or spinal cord, until proven otherwise at the hospital.\nSpinal stabilization must be initiated and maintained during the encounter.",
        "Car Versus Motorcycle": "Protection is from:\nHelmet\nLeather or abrasion-resistant clothing\nBoots When assessing the scene, look for:\nDeformity of the motorcycle\nSide of most damage\nDistance of skid in the road\nDeformity of stationary objects or other vehicles\nExtent and location of deformity in the helmet Head-on crash\nMotorcycle strikes another object and stops its forward motion while the rider continues moving forward.\nAngular crash\nMotorcycle strikes an object at an angle so that the rider sustains direct crushing injuries to the lower extremity. Ejection\nRider will travel at high speed until stopped by a stationary object, another vehicle, or road drag.\nControlled crash\nTechnique used to separate the rider from the body of the motorcycle",
        "Injury potential depends on the height from which the patient fell.": "More than 20 ft (6 m) is considered significant.\nInternal injuries pose the greatest threat to life. Patients who fall and land on their feet may have less-severe internal injuries.\nTheir legs may have absorbed much of the energy of the fall. FIGURE 25-14 When a patient falls and lands on his or\nher feet, the energy is transmitted to the spine, sometimes producing a spinal injury in addition to injuries to the legs and pelvis. \u00a9 Jones & Bartlett Learning. Take the following factors into account:\nThe height of the fall\nThe type of surface struck\nThe part of the body that hit first, followed by the path of energy displacement",
        "Penetrating Trauma": "Second-leading cause of trauma death after blunt trauma\nAccidentally by impalement\nIntentionally by a knife, ice pick, or other weapon FIGURE 25-15 Injuries from low-energy penetrations,\nsuch as a stab wound, are caused by the sharp edges of\nthe object moving through the body. \u00a9 Andrew Pollak, MD. Used with permission. With low-energy penetrations, injuries are caused by the sharp edges of the object moving through the body.\nKnives may have been deliberately moved around internally, causing more damage than the external wounds suggest. Path of the projectile may not be easy to predict.\nBullet may ricochet within the body before exiting.\nPath the projectile takes is its trajectory.\nFragmentation will increase damage. Cavitation results from rapid changes in tissue and fluid pressure that occur with the passage of the projectile. \nCan result in serious injury to internal organs FIGURE 25-16 Two types of injury are caused by cavitation\u2014temporary and permanent. \u00a9 Jones & Bartlett Learning. Relationship between distance and severity of injury varies depending on the type of weapon involved.\nAir resistance (drag) slows the projectile.\nArea damaged by projectiles is typically larger than the diameter of the projectile. \nEnergy available for a bullet to cause damage is more a function of its speed than its mass.",
        "Most common in military conflict": "Also seen in:\nMines\nShipyards\nChemical plants\nTerrorist attacks FIGURE 25-18 Mechanisms of blast injuries. \u00a9 Jones & Bartlett Learning. Primary blast injuries\nDue entirely to the blast itself\nDamage to the body by pressure wave\nSecondary blast injuries\nDamage to the body results from being struck by flying debris.\nTertiary blast injuries\nVictim is hurled by the force of the explosion. Quaternary (miscellaneous) blast injuries\nBurns from hot gases or fires started by the blast\nRespiratory injury from inhaling toxic gases\nCrush injury from the collapse of buildings\nMost patients will have some combination of the four types of injury. Organs that contain air are most susceptible to pressure changes.\nMiddle ear\nLung\nGastrointestinal tract\nThe ear is most sensitive to blast injuries. Pulmonary blast injuries result from short-range exposure to the detonation of explosives.\nArterial air embolisms can produce:\nDisturbances in vision\nChanges in behavior and state of consciousness\nVariety of other neurologic signs Solid organs are relatively protected from shock wave injury.\nNeurologic injuries and head trauma are the most common causes of death.\nTraumatic amputations are common.",
        "Multisystem Trauma Involves more than one body system": "Head and spinal trauma\nChest and abdominal trauma\nChest and multiple extremity trauma\nAlert medical control and transport rapidly.\nPatients have a high level of morbidity and mortality.",
        "Golden Principles of Prehospital Trauma Care": "Your main priority is to ensure:\nYour safety\nSafety of your crew\nSafety of the patient\nDetermine the need for additional personnel or equipment.\nEvaluate the MOI. Identify and manage life threats.\nThen focus on patient care.\nHemorrhage\nAirway and ventilatory support\nShock\nSpinal immobilization\nTransport immediately to the appropriate facility. Definitive care requires surgical intervention.\nOn-scene time should be limited to 10 minutes or less.\nObtain a SAMPLE history and complete a secondary assessment.\nConsider ALS intercept or air medical transportation.",
        "Patient Assessment When a patient has experienced a significant MOI and is critical condition, rapidly perform a physical examination.": "When a patient has experienced a nonsignificant MOI, focus on the chief complaint.",
        "Injuries to the Head Disability and unseen injury to the brain may occur.": "Bleeding or swelling inside the skull is often life threatening.\nInclude frequent neurologic examinations in your assessment.\nSome patients will not have obvious signs or symptoms.",
        "Injuries to the Neck and Throat": "Area of serious or deadly injuries\nAirway problems may result.\nLook for DCAP-BTLS in the neck region.\nSwelling may prevent blood flow to the brain. Penetrating injury may result in air embolism.\nCrushing injury may cause the cartilages of the upper airway and larynx to fracture.",
        "Injuries to the Chest": "Chest contains heart, lungs, and large blood vessels.\nMany life-threatening injuries may occur.\nBroken ribs may hinder breathing.\nHeart may be bruised.\nLarge vessels may be torn. A penetration or perforation of the integrity of the chest is called an open chest wound.\nIf untreated, shock and/or death will result.\nAssess the chest region every 5 minutes.\nAssessment should include DCAP-BTLS, lung sounds, and chest rise and fall.",
        "Injuries to the Abdomen": "Abdomen contains vital organs that require a very high amount of blood flow.\nSolid organs include the liver, spleen, pancreas, and kidneys.\nHollow organs include the stomach, large and small intestines, and urinary bladder. Solid organs may tear, lacerate, or fracture.\nHollow organs may rupture and leak toxic digestive chemicals.\nThe rupture of large blood vessels can cause serious unseen bleeding.",
        "Management: Transport and Destination": "Scene time\nSurvival of critically injured trauma patients is time dependent.\nLimit on-scene time to less than 10 minutes.\nCritically injured patient:\nDangerous MOI\nDecreased level of consciousness\nThreats to airway, breathing, or circulation Destination selection\nLevel I facility\nServes large cities or heavily populated areas\nProvides every aspect of trauma care\nUsually university-based hospitals\nLevel II facility \nLocated in less population-dense areas\nProvides initial definitive care Destination selection (cont\u2019d)\nLevel III facility\nProvides assessment, resuscitation, emergency care, and stabilization\nTransfers patients to Level I or Level II facility when necessary\nLevel IV facility\nFound in remote outlying areas\nProvides advanced trauma life support AAMS and MedEvac Foundation International identify criteria for emergency air medical services for trauma patients.\nExtended period required to access or extricate a remote or trapped patient\nPatient needs ALS care and no ALS-level ground ambulance service is available \nMultiple trauma patients \nMass-casualty incident Trauma centers are categorized as either adult trauma centers or pediatric trauma centers.\nDo not transport a pediatric patient to an adult trauma center when a pediatric trauma center is available. Type of transport\nGround EMS units are staffed by EMTs and paramedics.\nAir EMS units or critical care transport units are staffed by critical care nurses and paramedics. FIGURE 25-19 2011 decision scheme for field triage of injured patients. Adapted from Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report, January 13, 2012. Special considerations\nRemain calm.\nComplete an organized assessment.\nCorrect life-threatening injuries.\nDo no harm.\nNever hesitate to contact ALS backup or medical control for guidance."
    },
    {
        "National EMS Education Standard Competencies": "Trauma\nApplies fundamental knowledge to provide basic emergency care and transportation based on assessment findings for an acutely injured patient. Head, Facial, Neck, and Spine Trauma\nRecognition and management of\nLife threats\nSpine trauma Head, Facial, Neck, and Spine Trauma (cont\u2019d)\nPathophysiology, assessment, and management of\nSpine trauma\nSkull fractures Nervous System Trauma\nPathophysiology, assessment, and management of \nTraumatic brain injury\nSpinal cord injury",
        "Introduction": "The nervous system is a complex network of nerve cells that enables all parts of the body to function.\nIncludes:\nBrain\nSpinal cord\nNerves and nerve fibers The nervous system is well protected.\nThe brain is protected by the skull.\nThe spinal cord is protected by the spinal canal.\nDespite this protection, serious injuries can damage the nervous system.",
        "Anatomy and Physiology": "The nervous system is divided into two anatomic parts.\nCentral nervous system\nPeripheral nervous system FIGURE 29-1 The nervous system has two anatomic components: the central nervous system and the peripheral nervous system. The central nervous system is composed of the brain and the spinal cord. The peripheral nervous system conducts sensory and motor impulses from the skin and other organs to the spinal cord. \u00a9 Jones & Bartlett Learning.",
        "Includes the brain and spinal cord": "The brain controls the body and is the center of consciousness.\nBrain is divided into three major areas:\nCerebrum\nCerebellum\nBrainstem FIGURE 29-2 The brain is part of the central nervous  system and is the organ that controls the body. It is divided into three major areas: the cerebrum, the cerebellum, and the brainstem. \u00a9 Jones & Bartlett Learning. Cerebrum\nControls a wide variety of activities, including most voluntary motor function and conscious thought\nContains about 75% of the brain\u2019s total volume\nDivided into two hemispheres with four lobes Cerebellum\nCoordinates balance and body movements\nBrainstem\nControls most functions necessary for life\nBest-protected part of the CNS Spinal cord\nMade up of fibers that extend from the brain\u2019s nerve cells\nCarries messages between the brain and the body via the grey and white matter of the spinal cord Protective coverings\nThe entire CNS is contained within a protective framework.\nThe thick, bony structures of the skull and spinal canal withstand injury very well.\nThe CNS is further protected by the meninges. Meninges\nOuter layer (dura mater) is a tough, fibrous layer that forms a sac to contain the CNS.\nInner two layers (arachnoid mater and pia mater) contain the blood vessels. FIGURE 29-3 The central nervous system has several layers of protective coverings: the skin, muscles and their fascia, bone, and the meninges. The three layers of the meninges are the dura mater, the arachnoid, and the pia mater. \u00a9 Jones & Bartlett Learning. Cerebrospinal fluid (CSF)\nProduced in a chamber inside the brain called the third ventricle\nApproximately 125 to 150 mL of CSF in the brain at any time\nPrimarily acts as a shock absorber",
        "31 pairs of spinal nerves": "Conduct impulses from the skin and other organs to the spinal cord\nConduct motor impulses from the spinal cord to the muscles FIGURE 29-4 The peripheral nervous system is a complex network of motor and sensory nerves. The brachial plexus controls the arms, and the lumbosacral plexus controls the legs. \u00a9 Jones & Bartlett Learning. 12 pairs of cranial nerves\nTransmit information directly to or from the brain\nPerform special functions in the head and face, including sight, smell, taste, hearing, and facial expressions Two types of peripheral nerves\nSensory nerves\nCarry only one type of information from the body to the brain via the spinal cord\nMotor nerves\nOne for each muscle\nCarry information from the CNS to the muscles Connecting nerves\nFound only in the brain and spinal cord\nConnect the sensory and motor nerves with short fibers\nAllow the exchange of simple messages",
        "How the Nervous System Works": "Controls virtually all the body\u2019s activities, including:\nReflex activities\nVoluntary activities\nInvoluntary activities Connecting nerves in the spinal cord form a reflex arc.\nIf a sensory nerve in this arc detects an irritating stimulus, it bypasses the brain and sends the message directly to a motor nerve. FIGURE 29-5 The connecting nerves in the spinal cord form a reflex arc. If a sensory nerve in this arc detects an irritating stimulus, it will bypass the brain and send a direct message to a motor nerve. \u00a9 Jones & Bartlett Learning. Voluntary activities are activities we consciously perform.\nInvoluntary activities are the actions that are not under conscious control.\nSomatic (voluntary) nervous system handles voluntary activities. Autonomic (involuntary) nervous system handles body functions.\nDivided into two sections: sympathetic and parasympathetic nervous systems\nSympathetic nervous system reacts to stress with a fight-or-flight response.\nParasympathetic nervous system has the opposite effect on the body.",
        "Skeletal System": "Skull\nComposed of two groups of bones: cranium and facial bones. FIGURE 29-6 The skull includes two large structures: the cranium and the face. \u00a9 Jones & Bartlett Learning. Skull (cont\u2019d)\nThe brain connects to the spinal cord through the foramen magnum.\nFour major bones make up the cranium: occipital, temporal, parietal, and frontal.\nFace is composed of 14 bones: maxillae, zygomas, mandible, and orbit. Spinal column\nBody\u2019s central supporting structure\n33 vertebrae are divided into five sections:\nCervical\nThoracic\nLumbar\nSacral\nCoccygeal FIGURE 29-7 The spinal column is the body\u2019s central\nsupporting system and consists of 33 bones divided into\nfive sections. Injury to the vertebrae may cause paralysis. \u00a9 Jones & Bartlett Learning. Spinal column (cont\u2019d)\nInjury to the vertebrae can result in paralysis.\nVertebrae are connected by ligaments and separated by cushions, called intervertebral disks.\nSpinal column is almost entirely surrounded by muscles.",
        "Traumatic insult to the head that may result in injury to soft tissue, bony structures, or the brain.": "Account for more than half of all traumatic deaths\nThe patient may have sustained additional trauma. Closed injuries\nThe brain has been injured but there is no opening into the brain.\nOpen injuries\nAn opening from the brain to the outside world exists.\nOften caused by penetrating trauma\nMay be bleeding and exposed brain tissue Falls and motor vehicle crashes are among the most common MOI.\nHead injuries also commonly occur:\nIn victims of assault\nDuring sports-related incidents",
        "Scalp Lacerations Can be minor or serious": "Even small lacerations can lead to significant blood loss.\nMay be severe enough to cause hypovolemic shock\nThey are often an indicator of deeper, more serious injuries.",
        "Significant force applied to the head may cause a skull fracture.": "May be open or closed, depending on whether there is an overlying laceration of the scalp\nInjuries from bullets or other penetrating weapons often result in skull fractures. Signs of skull fracture include:\nPatient\u2019s head appears deformed.\nVisible cracks in the skull\nEcchymosis (bruising) that develops under the eyes (raccoon eyes)\nEcchymosis that develops behind one ear over the mastoid process (Battle sign) FIGURE 29-10 Signs of skull fracture include ecchymosis under the eyes (raccoon eyes) (A) or behind one ear over the mastoid process (Battle sign) (B). A: \u00a9 E. M. Singletary, MD. Used with permission; B: \u00a9 Mediscan/Alamy. Linear skull fractures\nAccount for about 80% of all skull fractures\nRadiographs are required to diagnose a linear skull fracture because there are no physical signs. FIGURE 29-11A Types of skull fractures. Linear. \u00a9 Jones & Bartlett Learning. Depressed skull fractures\nResult from high-energy direct trauma to the head with a blunt object\nFrontal and parietal bones are most susceptible.\nBony fragments may be driven into the brain. \u00a9 Jones & Bartlett Learning. FIGURE 29-11B Types of skull fractures.  Depressed. Basilar skull fractures\nAssociated with high-energy trauma\nUsually occur following diffuse impact to the head\nSigns include CSF drainage from the ears, raccoon eyes, and Battle sign. \u00a9 Jones & Bartlett Learning. FIGURE 29-11C Types of skull fractures. Basilar. Open skull fractures\nOften associated with trauma to multiple body systems\nBrain tissue may be exposed to the environment.\nHigh mortality rate \u00a9 Jones & Bartlett Learning. FIGURE 29-11D Types of skull fractures. Open.",
        "Traumatic Brain Injuries": "Most serious of all head injuries\nTwo broad categories: primary (direct) injury and secondary (indirect) injury\nPrimary brain injury results instantaneously from impact to the head.\nSecondary brain injury increases the severity of the primary injury. Secondary injury may be caused by:\nHypoxia\nHypotension\nCerebral edema\nIntracranial hemorrhage\nIncreased intracranial pressure\nCerebral ischemia\nInfection The brain can be injured directly by a penetrating object or indirectly as a result of external forces.\nA coup-contrecoup injury can result from striking a windshield.\nHead hits the windshield; brain comes to an abrupt stop by striking the inside of the skull.\nHead falls back against headrest; brain slams into the rear of the skull. Cerebral edema may not develop for several hours.\nLow blood oxygen levels aggravate cerebral edema.\nMonitor the patient for any seizure activity.",
        "Accumulations of blood within the skull or swelling of the brain can rapidly lead to an increase in ICP.": "Increased ICP squeezes the brain against bony prominences within the cranium. Signs of increased intracranial pressure \nCheyne-Stokes respirations\nAtaxic (Biot) respirations\nDecreased pulse rate, headache, nausea, vomiting, decreased alertness, bradycardia, sluggish or nonreactive pupils, decerebrate posturing, and increased or widened blood pressure. \nCushing reflex Intracranial hemorrhage\nBleeding inside the skull also increases the ICP.\nBleeding can occur:\nBetween the skull and dura mater\nBeneath the dura mater but outside the brain\nWithin the tissue of the brain itself Epidural hematoma\nAccumulation of blood between the skull and dura mater\nNearly always the result of a blow to the head that produces a linear fracture FIGURE 29-13 An epidural hematoma is usually the result of a blow to the head that produces a linear fracture of the temporal bone and damages the middle meningeal artery. Blood accumulates between the dura mater and the skull. \u00a9 Jones & Bartlett Learning. Subdural hematoma\nAccumulation of blood beneath the dura mater but outside the brain\nOccurs after falls or injuries involving strong deceleration forces\nMay or may not be skull fracture FIGURE 29-14 In a subdural hematoma, venous bleeding occurs beneath the dura mater but outside the brain. \u00a9 Jones & Bartlett Learning. Intracerebral hematoma\nBleeding within the brain tissue itself\nCan occur following a penetrating injury to the head or because of rapid deceleration forces FIGURE 29-15 An intracerebral hematoma involves\nbleeding within the brain tissue itself. \u00a9 Jones & Bartlett Learning. Subarachnoid hemorrhage\nBleeding occurs into the subarachnoid space, where the CSF circulates.\nResults in bloody CSF and signs of meningeal irritation\nCommon causes include trauma or rupture of an aneurysm.",
        "A blow to the head or face may cause concussion of the brain.": "Closed injury with a temporary loss or alteration of part or all of the brain\u2019s abilities to function without demonstrable physical damage to the brain\nAbout 90% of patients do not experience a loss of consciousness. A patient with a concussion may be confused or have amnesia.\nUsually a concussion lasts only a short time. Ask about these symptoms:\nDizziness\nWeakness\nVisual changes\nNausea and vomiting\nRinging in the ears\nSlurred speech\nInability to focus",
        "Contusion Far more serious than a concussion": "Involves physical injury to brain tissue\nMay sustain long-lasting and even permanent damage\nA patient may exhibit any or all of the signs of brain injury.",
        "Other Brain Injuries Brain injuries can also arise from medical conditions, such as blood clots or hemorrhages.": "Signs and symptoms of nontraumatic injuries are often the same as those of traumatic brain injuries.",
        "Spine Injuries": "Compression injuries can result from a fall.\nForces that compress the patient\u2019s vertebral body can cause herniation of disks. \nMotor vehicle crashes can overextend the spine.\nRotation-flexion injuries of the spine result from rapid acceleration forces. When the spine is pulled along its length (hyperextension), it can cause fractures.\nAny one of these unnatural motions, as well as excessive lateral bending, can result in fractures or neurologic deficit. \nWhen bones of the spine are altered from traumatic forces, they can fracture or move out of place.",
        "Patient Assessment": "Always suspect a possible head or spinal injury with:\nMotor vehicle collisions\nPedestrian\u2013motor vehicle collisions\nFalls\nBlunt trauma\nPenetrating trauma to the head, neck, back, or torso Always suspect a possible head or spinal injury with (cont\u2019d):\nRapid deceleration injuries\nHangings\nAxial loading injuries \nDiving accidents",
        "Scene Size-up": "Scene safety\nEvaluate every scene for hazards to your health and the health of your team or bystanders.\nBe prepared with appropriate standard precautions.\nCall for ALS as soon as possible. Mechanism of injury/nature of illness\nLook for indicators of the MOI.\nConsider how the MOI produced the injuries expected.",
        "Primary Assessment": "Focus on identifying and managing life-threatening concerns.\nReduction of on-scene time and recognition of a critical patient increase the patient\u2019s chances for survival or a reduction in the amount of irreversible damage. Spinal immobilization considerations\nAssess the patient in the position found. \nDetermine whether or not a cervical collar needs to be applied. \nAssess the scene to determine the risk of injury.\nForm a general impression based on level of consciousness and chief complaint. The backboard often places the patient in an anatomically incorrect position for a long period of time. \nCirculation to areas of skin may become compromised.\nSome patients could experience respiratory compromise while lying flat. \nTry to minimize the amount of time a patient is on a backboard. Cervical collar\nHelps maintain spinal motion restriction \nThe best time to apply the cervical collar depends on the patient\u2019s injuries. \nOnce the cervical collar is on, do not remove it unless it causes a problem with maintaining the airway. Assessing for signs and symptoms of a head or spine injury \nAsk about the chief complaint.\nConfused or slurred speech, repetitive questioning, or amnesia in responsive patients are good indications of a head injury.\nIn the setting of trauma, assume your patient has a head injury until your assessment proves otherwise. Assessing for signs and symptoms of a head or spine injury (cont\u2019d)\nUnresponsive trauma patients should be assumed to have a spinal injury. \nPatients with a decreased level of responsiveness should be considered to have a spinal injury based on their chief complaint. Airway, breathing, and circulation considerations\nUse a jaw-thrust maneuver to open the airway.\nIf the jaw-thrust maneuver is ineffective, use the head tilt\u2013chin lift maneuver as a last resort.\nVomiting may occur in the patient with a head injury.\nIrregular breathing may result from increased ICP. Airway, breathing, and circulation considerations (cont\u2019d)\nOxygen is always indicated for patients with head and spinal injuries.\nPulse oximeter values should be maintained above 90%.\nHyperventilation should be reserved for specific conditions. Airway, breathing, and circulation considerations (cont\u2019d)\nA pulse that is too slow in the setting of a head injury can indicate a serious condition.\nA single episode of hypoperfusion in a patient with a head injury can lead to significant brain damage and even death.\nAssess for signs and symptoms of shock.\nControl bleeding. Manner of transport\nPatients with impaired airways, open head wounds, or abnormal vital signs may need to be rapidly extracted from a motor vehicle and transported.\nEnsuring a patent airway and providing supplemental oxygen is paramount.\nSuction should be readily available.\nMaintain immobilization of the spine.",
        "History Taking Investigate the chief complaint.": "Obtain a medical history and be alert for injury-specific signs and symptoms.\nUsing OPQRST may provide some background on isolated extremity injuries.\nGather as much SAMPLE history as you can while preparing for transport.",
        "Secondary Assessment": "Instruct the patient to keep still and not to move the head or neck.\nPhysical examinations\nMay be a systematic head-to-toe, full-body scan or a systematic assessment that focuses on a certain area or region of the body Physical examinations (cont\u2019d)\nVital signs\nSignificant head injuries may cause the pulse to be slow and the BP to rise.\nWith neurogenic shock, the blood pressure may drop, and the heart rate may increase to compensate. \nRespirations will become erratic.\nUse monitoring devices. Physical examinations (cont\u2019d)\nUse DCAP-BTLS to examine the head, chest, abdomen, extremities, and back.\nCheck perfusion, motor function, and sensation in all extremities prior to moving the patient. Physical examinations (cont\u2019d)\nA decreased level of consciousness is the most reliable sign of a head injury.\nLook for leaking blood or CSF.\nAssess pupil size and reaction to light, and continue to monitor the pupils.\nDo not probe open scalp lacerations with your gloved finger. Neurologic examination \nPerform baseline assessment using the Glasgow Coma Scale (GCS).\nIf your jurisdiction uses the Revised Trauma Score (RTS), then the findings from the GCS will be used in determining the RTS value.\nRecord levels of consciousness that fluctuate or deteriorate. Spine examination\nInspect for DCAP-BTLS, and check the extremities for circulation, motor, or sensory problems.\nIf there is impairment, note the level.\nPain or tenderness when you palpate is a warning sign.\nOther signs and symptoms: deformity, numbness, weakness, or tingling in the extremities; and soft-tissue injuries",
        "Reassessment": "Repeat the primary assessment.\nReassess vital signs and the chief complaint.\nRecheck patient interventions.\nReassess at least every 5 minutes. Interventions\nCompare baseline vital signs with repeated vital signs. \nRapid deterioration of neurologic signs is a sign of an expanding bleed in the brain or rapidly progressing brain swelling. Interventions (cont\u2019d)\nIf CSF is present, cover the wound with sterile gauze, but do not bandage tightly.\nAdminister high-flow oxygen and apply a cervical collar. Communication and documentation\nYour documentation should include:\nThe history you obtained at the scene\nYour findings during your assessment\nTreatments you provided\nHow the patient responded to them\nDocument vital signs for unstable patients every 5 minutes; every 15 for stable patients.",
        "Emergency Medical Care of Head Injuries": "Three general principles:\nEstablish an adequate airway.\nControl bleeding and provide adequate circulation to maintain cerebral perfusion.\nAssess the patient\u2019s baseline level of consciousness, and continuously monitor. Managing the airway\nPerform the jaw-thrust maneuver.\nOnce the airway is open, maintain the head and cervical spine in a neutral, in-line position until you have placed a cervical collar and have secured the patient on a backboard. FIGURE 29-20 Apply a cervical collar as you finish the primary assessment. \u00a9 Jones & Bartlett Learning. Photo by Darren Stahlman. Managing the airway (cont\u2019d)\nRemove any foreign bodies, secretions, or vomitus.\nCheck ventilation.\nGive supplemental oxygen to any patient with suspected head injury. Circulation\nBegin CPR if the patient is in cardiac arrest.\nActive blood loss aggravates hypoxia.\nYou can almost always control bleeding from a scalp laceration by applying direct pressure over the wound. Shock is usually the result of hypovolemia.\nIndicates that the situation is critical \nTransport immediately to a trauma center. Cushing triad\nIncreased blood pressure (hypertension)\nDecreased heart rate (bradycardia)\nIrregular respirations (Cheyne-Stokes respirations or Biot respirations)\nManage shock, administer oxygen, and ventilate as necessary, avoiding hyperventilation.",
        "Emergency Medical Care of Spinal Injuries": "Follow standard precautions.\nMaintain the patient\u2019s airway while keeping the spine in the proper position.\nAssess respirations and give supplemental oxygen. Managing the airway\nPerform the jaw-thrust maneuver.\nConsider inserting an oropharyngeal airway.\nHave a suctioning unit available.\nProvide supplemental oxygen. FIGURE 29-22 Jaw-thrust maneuver. A. Stabilize the neck in a neutral, in-line position. B. Push the angle of the lower jaw upward. A, B: \u00a9 Jones & Bartlett Learning. Courtesy of MIEMSS. Spinal motion restriction of the cervical spine\nImmobilize the head and trunk so that bone fragments do not cause further damage.\nNever force the head into a neutral, in-line position.\nImmobilize the patient in his or her current position. Cervical collars \nProvide preliminary, partial support\nShould be applied to every patient who has a possible spinal injury \nTo be effective, a rigid cervical collar must be the correct size. FIGURE 29-23 Proper fit is essential in applying a cervical\ncollar. The collar should rest on the shoulder girdle and\nprovide firm support under both sides of the mandible\nwithout obstructing the airway or any ventilation efforts. \u00a9 Jones & Bartlett Learning. Cervical collars (cont\u2019d)\nOnce the patient\u2019s head and neck have been manually stabilized, assess the pulse, motor functions, and sensation in all extremities. Then assess the cervical spine area and neck. \nMaintain manual support until the patient has been fully secured to the backboard or vacuum mattress.",
        "Preparation for Transport": "Supine patients\nSecure to a long backboard or vacuum mattress.\nAnother procedure to move a patient from the ground to a backboard is the four-person log roll.\nYou may also slide the patient onto a backboard or vacuum mattress. Vacuum mattress\nAn alternative to the long backboard is a vacuum mattress.\nMolds to the specific contours of patient\u2019s body \nExcellent for the elderly or a patient with abnormal curvature of the spine\nCan be used on a supine, sitting, or standing patient Sitting patients\nUse a short backboard to restrict movement of the cervical and thoracic spine.\nThen secure the short board to the long board.\nExceptions include situations in which:\nYou or the patient is in danger.\nYou need immediate access to other patients.\nThe patient\u2019s injuries justify urgent removal. Standing patients\nTransfer patient to a position in which spinal motion restriction can be maintained.\nClinical indications for spinal motion restriction:\nSpinal tenderness or pain\nAltered level of consciousness\nNeurologic deficits\nObvious spinal deformity\nHigh-energy trauma in an intoxicated patient or one with a distracting injury Spinal immobilization devices\nAssume the presence of spinal injury in all patients who have sustained head injuries.\nUse manual in-line stabilization or a cervical collar and long backboard. Short backboards\nVest-type device and rigid short board\nDesigned to immobilize and restrict movement of the head, neck, and torso\nUsed to immobilize noncritical patients found in a sitting position FIGURE 29-25 A common short-board spinal precaution device is a vest-type device. \u00a9 Kendrick EMS. Long backboards\nProvide full body spinal immobilization and motion restriction to the head, neck, torso, pelvis, and extremities\nUsed to immobilize patients found in any position FIGURE 29-26 Long backboards provide full-body spinal motion restriction, including the head, neck, torso, pelvis, and extremities. \u00a9 meenon/iStock/Getty Images Plus/Getty Images.",
        "Helmet Removal": "A helmet that fits well prevents the patient\u2019s head from moving and should be left on, provided:\nThere are no impending airway or breathing problems.\nIt does not interfere with assessment and treatment of airway or ventilation problems.\nYou can properly immobilize the spine. Remove a helmet if:\nIt is a full-face helmet.\nIt makes assessing or managing airway problems difficult. \nIt prevents you from properly immobilizing the spine.\nIt allows excessive head movement.\nThe patient is in cardiac arrest. Preferred method\nRemoving a helmet should always be at least a two-person job.\nYou should first consult with medical control about your decision to remove a helmet. Alternate method\nThe advantage is that it allows the helmet to be removed with the application of less force, therefore reducing the likelihood of motion occurring in the neck.\nThe disadvantage is that it is slightly more time consuming. Alternate method (cont\u2019d)\nRemove the chin strap.\nRemove the face mask.\nPop the jaw pads out of place.\nPlace your fingers inside the helmet.\nHold the jaw with one hand and the occiput with the other.\nInsert padding behind the occiput. Alternate method (cont\u2019d)\nThe person at the side of the patient\u2019s chest is responsible for making sure that the head and neck do not move during removal of the helmet.\nRemember that children may require additional padding to maintain the in-line neutral position."
    },
    {
        "National EMS Education Standard Competencies": "Trauma\nApplies fundamental knowledge to provide basic emergency care and transportation based on assessment findings for an acutely injured patient. Abdominal and Genitourinary Trauma\nRecognition and management of\nBlunt versus penetrating mechanisms\nEvisceration\nImpaled object Pathophysiology, assessment, and management of\nSolid and hollow organ injuries\nBlunt versus penetrating mechanisms\nEvisceration\nInjuries to the external genitalia\nVaginal bleeding due to trauma\nSexual assault",
        "Introduction": "The abdomen extends from the diaphragm to pelvis.\nContains organs that make up digestive, urinary, and genitourinary systems Significant trauma to the abdomen can occur from blunt trauma, penetrating trauma, or both. \nInjuries to the abdomen that go unrecognized or are not repaired in surgery are a leading cause of traumatic death.",
        "Anatomy and Physiology of the Abdomen": "Abdomen is divided into four general quadrants.\nQuadrant of bruising/pain can delineate which organs are involved.\nRUQ: Liver, gallbladder, duodenum, pancreas\nLUQ: Stomach and spleen\nLLQ: Descending colon, left transverse colon\nRLQ: Large and small intestine, appendix RLQ is a common location for swelling and inflammation.\nThe appendix is a source of infection if it ruptures. FIGURE 31-1 Locations on the abdomen are often designated according to four quadrants. \u00a9 Jones & Bartlett Learning. Hollow organs\nStomach, intestines, ureters, bladder\nWhen ruptured or lacerated, contents spill into peritoneal cavity.\nCan cause intense inflammatory reaction and infection such as peritonitis Hollow organs (cont\u2019d)\nIntestinal blood supply comes from mesentery.\nConnects the small intestine to the abdominal wall\nPatients with injuries to the mesentery can bleed into the peritoneal cavity. FIGURE 31-2 The hollow organs in the abdominal cavity\nare structures through which materials pass. FIGURE 31-3 The solid organs are solid masses of tissue\nthat do much of the chemical work in the body and receive a large, rich supply of blood. \u00a9 Jones & Bartlett Learning. \u00a9 Jones & Bartlett Learning. Solid organs\nLiver, spleen, pancreas, kidneys\nPerform chemical work of the body: enzyme production, blood cleansing, energy production\nBecause of rich blood supply, hemorrhage can be severe.",
        "Injuries to the Abdomen Injuries to the abdomen are considered either open or closed.": "Can involve hollow and/or solid organs",
        "Closed Abdominal Injuries": "Blunt trauma to abdomen\nMOIs:\nMotor vehicle crashes\nMotorcycle crashes\nFalls\t\nBlast injuries\nPedestrian versus bicycle\nRapid deceleration\nCompression Signs and symptoms\nBlood in peritoneal cavity produces acute pain in entire abdomen.\nAbdominal distention is often the result of free fluid, blood, or organ contents spilling into peritoneal cavity.\nAbdominal bruising and discoloration Seat belts \nMay cause blunt injuries of abdominal organs\nParticularly when belt lies too high\nCan cause bladder injuries to pregnant patients\nRemember to inspect beneath the airbag for signs of damage to the steering column. FIGURE 31-5 Diagrams A and B show improper positioning of lap seat belts. The proper position for a seat belt is below the anterior superior iliac spines of the pelvis and against the hip joints, as shown in diagram C. A, B, C: \u00a9 Jones & Bartlett Learning.",
        "Open Abdominal Injuries": "Foreign object enters abdomen and opens peritoneal cavity to the outside.\nOpen wounds can be deceiving.\nMaintain a high index of suspicion. Damage depends on velocity of object.\nLow-velocity injuries\nKnives, other edged weapons\nMedium-velocity injuries\nSmaller caliber handguns and shotguns\nHigh-velocity injuries\nHigh-powered rifles and handguns High- and medium-velocity injuries\nHave temporary wound channels\nCaused by cavitation\nCavity forms as pressure wave from projectile transfers to tissues.\nCan produce large amounts of bleeding Low-velocity injuries\nAlso have capacity to damage organs\nInternal injury may not be apparent.\nIf injury is at or below xiphoid process, assume it has affected the thoracic and peritoneal cavities. Evisceration: bowel protrudes from peritoneum\nCan be painful and visually shocking\nDo not push down on abdomen.\nOnly perform visual assessment.\nCut clothing close to wound.\nNever pull on clothing stuck to or in the wound channel.",
        "Hollow Organ Injuries": "Often have delayed signs and symptoms\nSpill contents into abdomen\nInfection develops, which can take hours or days.\nStomach and intestines can leak highly toxic and acidic liquids into peritoneal cavity. Caused by blunt and penetrating trauma\nBlunt trauma causes organ to \u201cpop,\u201d releasing fluids and air.\nPenetrating trauma causes direct injury.\nGallbladder and urinary bladder\nContents are damaging.\nAir in peritoneal cavity causes pain.\nCan cause ischemia and infarction",
        "Solid Organ Injuries": "Can bleed significantly and cause rapid blood loss\nCan be hard to identify from physical exam\nSlowly ooze blood into peritoneal cavity Liver is the largest organ in abdomen.\nVascular and can lead to hypoperfusion\nOften injured by fractured lower right rib or penetrating trauma\nReferred pain to the right shoulder is a common finding with an injured liver. Spleen and pancreas\nVascular and prone to heavy bleeding\nSpleen is often injured. \nMotor vehicle collisions\nSteering wheel trauma\nFalls from heights \nBicycle and motorcycle accidents involving handlebars Diaphragm \nWhen penetrated or ruptured, loops of bowels invade thoracic cavity.\nPatient may exhibit dyspnea. Kidneys\nCan cause significant blood loss\nCommon finding is blood in urine. \nBlood visible on urinary meatus indicates significant trauma to genitourinary system.",
        "Patient Assessment of Abdominal Injuries Assessment of abdominal injuries is difficult.": "Causes of injury may be apparent but resulting tissue damage may not be.\nPatient may be overwhelmed with more painful injuries.\nSome injuries develop and worsen over time.",
        "Scene size-up": "Standard precautions of gloves and eye protection should be a minimum.\nBe sure scene is safe for you.\nCall for additional resources early if needed. Mechanism of injury/nature of illness\nObserve the scene for early indicators of MOI.\nConsider early spinal precautions.\nConsider all of the injuries the MOI could have produced. Scene Size-up Scene safety\nAssess the scene for hazards and threats.\nApply standard precautions.\nLook for indicators of MOI.\nPatient may avoid discussion to avoid undergoing physical exam.\nPatient may provide an MOI that seems less embarrassing than the actual MOI.",
        "Primary Assessment": "Quickly form a general impression and note the patient\u2019s level of consciousness.\nSevere external hemorrhage must be addressed before airway or breathing.\nEnsure that the patient has a patent airway. Circulation \nTreat signs and symptoms of shock aggressively.\nTransport decision\nPatients with abdominal injuries should be evaluated at the highest level of trauma center available. Quickly scan patient to identify and treat life threats.\nGenitourinary system is very vascular.\nLife-threatening hemorrhage must be addressed immediately. Airway and breathing\nEnsure the patient has a clear and patent airway.\nProvide assisted ventilations with bag-mask device as needed.\nConsider advanced airway if patient is unresponsive. Circulation\nAssess pulse rate and quality.\nClosed injuries do not have visible signs of bleeding.\nTreat for shock. Transport decision\nAny injury to the genitourinary system can be life altering.\nTransport to a trauma center.",
        "History Taking": "Investigate chief complaint and MOI\nIdentify signs, symptoms, and pertinent negatives.\nMovement of body or abdominal organs irritates peritoneum, causing pain. SAMPLE history\nUse OPQRST to help explain injury.\nAsk if there is nausea, vomiting, or diarrhea.\nAsk about appearance of any bowel movements and urinary output. Investigate chief complaint.\nCommon associated complaints with genitourinary injuries are:\nNausea and vomiting\nDiarrhea\nBlood in urine\nVomiting blood\nAbnormal bowel and bladder habits SAMPLE history\nUse OPQRST to learn about patient\u2019s pain.\nAsk patient about output. \nEspecially blood in urine\nAsk about allergies. \nLast intake of food and fluid\nAddress events leading up to injury.",
        "May not have time to perform in the field": "Physical examinations\nInspect for bleeding.\nRemove or loosen clothes to expose injuries.\nPatient should remain in position of comfort.\nExamine entire abdomen. Physical examinations (cont\u2019d)\nUse DCAP-BTLS.\nInspect and palpate for deformities.\nLook for presence of contusions, abrasions, puncture wounds, penetrating injuries, burns.\nPalpate for tenderness and attempt to localize to specific quadrant of abdomen.\nSwelling may indicate significant intra-abdominal injury. Physical examinations (cont\u2019d)\nPalpate the quadrant farthest away from quadrant exhibiting signs of injury and pain.\nAllows you to investigate possibility of radiation of pain\nPerform full-body scan to identify injuries.\nIf you find life threat, stop and treat it.\nAssess need for spinal immobilization. Physical examinations (cont\u2019d)\nInspect and palpate kidney area for tenderness, bruising, swelling, or other trauma signs.\nHollow organs will spill contents into peritoneal cavity. Vital signs\nMany abdominal emergencies can cause a rapid pulse and low blood pressure.\nRecord of vital signs will help identify changes in condition.\nUse appropriate monitoring devices. Secondary Assessment Physical examinations\nGenitourinary system injuries can be awkward to assess and treat.\nFocus on specific region of body when isolated injury is present.\nLook for DCAP-BTLS.\nIdentify wounds and control bleeding.\nObtain vital signs and reassess frequently.",
        "Assessment of an Isolated Abdominal Injury Visually inspect the abdomen for penetrating wounds.": "If an entrance wound is found, check for a corresponding exit wound.\nDo not remove an impaled object.",
        "Reassessment Repeat the primary assessment and reassess vital signs.": "Reassess interventions and treatment.\nCommunication and documentation\nOutline the patient\u2019s MOI, injuries, and relevant vital signs. Reassessment Interventions\nRepeat primary assessment and vital signs.\nReassess interventions and treatment.\nAdjust interventions as needed.\nCommunication and documentation\nCommunicate all concerns to hospital staff.\nDescribe and document all injuries and treatments given.",
        "Emergency Medical Care of Abdominal Injuries": "Closed abdominal injuries\nMonitor and evaluate for progression into shock.\nThe patient may experience nausea and vomiting.\nAdminister oxygen to patients who are unconscious or in shock.\nAssist ventilations if necessary.\nConsider calling ALS for gastric tube placement. Open abdominal injuries\nPatients with penetrating injuries \nGenerally obvious wounds, external bleeding\nMaintain a high index of suspicion for serious unseen blood loss. Open abdominal injuries (cont\u2019d)\nInspect patient\u2019s back and sides for exit wound.\nApply dry, sterile dressing to all open wounds.\nIf penetrating object is still in place, apply stabilizing bandage around it. Evisceration\nSevere lacerations of abdominal wall may result in internal organs or fat protruding through wound. FIGURE 31-10 An abdominal evisceration is an open abdominal wound from which internal organs protrude. \u00a9 Arucha Srimuang/Shutterstock. Evisceration (cont\u2019d)\nNever try to replace a protruding organ.\nKeep the organs moist and warm.\nCover with moistened, sterile dressings.\nSecure dressing with bandage.\nSecure bandage with tape. FIGURE 31-11 A. The open abdomen radiates body heat rapidly and must be covered. B. Cover the wound with moistened, sterile dressings and with an occlusive dressing, depending on local protocol. C. Secure the dressing with a bandage. D. Secure the bandage with tape. A-D: \u00a9 Jones & Bartlett Learning.",
        "Anatomy of the Genitourinary System": "Controls reproductive functions and waste discharge\nOrgans of the genitourinary system are located in the abdomen.\nMale genitalia lie outside pelvic cavity.\nFemale genitalia lie within pelvic cavity. FIGURE 31-13 The male reproductive system includes the testicles, vas deferens, seminal vesicles, prostate gland, urethra, and penis. \u00a9 Jones & Bartlett Learning. FIGURE 31-14 The female reproductive system includes the ovaries, fallopian tubes, uterus, cervix, and vagina. \u00a9 Jones & Bartlett Learning.",
        "Injuries of the Genitourinary System": "Kidney injuries\nNot uncommon and rarely occur in isolation\nKidneys lie in well-protected area.\nForceful blow or penetrating injury often involved Suspect kidney damage if patient has evidence of any of the following:\nAbrasion, laceration, contusion on the flank\nPenetrating wound in region of flank or upper abdomen\nFractures on either side of lower rib cage or of lower thoracic or upper lumbar vertebrae\nA hematoma in the flank region Urinary bladder injuries\nMay result in rupture\nUrine spills into surrounding tissues.\nBlunt injuries to lower abdomen or pelvis can rupture urinary bladder.\nIn males, sudden deceleration can shear the bladder from the urethra.\nIn later trimesters of pregnancy, bladder injuries increase. FIGURE 31-16 Fracture of the pelvis can result in perforation of the bladder by the bony fragments. Urine then leaks into the pelvis. \u00a9 Jones & Bartlett Learning. External male genitalia injuries\nSoft-tissue wounds\nPainful and of great concern for patient\nRarely life threatening\nShould not be given priority over more severe wounds unless there is severe bleeding\nPain may be referred to the lower abdomen. Female genitalia injuries\nInternal female genitalia\nUterus, ovaries, fallopian tubes are rarely damaged.\nException is pregnant uterus.\nUterus enlarges substantially and rises out of pelvis.\nInjuries can be serious. \nAlso keep fetus in mind. Female genitalia injuries (cont\u2019d)\nExternal female genitalia\nVulva, clitoris, major and minor labia\nVery rich nerve supply\nConsider sexual assault and pregnancy.\nIf external bleeding, a sterile absorbent sanitary pad may be applied to the labia.\nDo not insert anything into the vagina.",
        "Patient Assessment of the Genitourinary System Potential for patient embarrassment": "Maintain a professional presence.\nProvide privacy.\nHave EMT of same gender perform assessment.",
        "Emergency Medical Care of Genitourinary Injuries": "Kidney injuries\nInjuries may not be obvious.\nYou will see signs of shock and blood in urine. \nTreat for shock, transport promptly, and monitor vital signs en route. Urinary bladder injury\nSuspect if you see:\nBlood at urethral opening\nSigns of trauma to lower abdomen, pelvis, or perineum\nIn presence of shock or associated injuries:\nTransport promptly.\nMonitor vital signs en route. External male genitalia\nMake patient comfortable.\nUse sterile, moist compresses to cover areas stripped of skin.\nApply direct pressure with dry, sterile gauze dressings to control bleeding.\nNever move or manipulate foreign objects in urethra. External male genitalia (cont\u2019d)\nIdentify and take avulsed parts in bag to hospital with patient.\nAmputation of penile shaft\nManaging blood loss is top priority.\nUse local pressure with sterile dressing.\nSurgical reconstruction is possible if you can locate the amputated part. External male genitalia (cont\u2019d)\nWhen an erect penis is bent sharply, the shaft can be severely damaged.\nSometimes requires surgical repair\nAssociated with intense pain, bleeding, and fear External male genitalia (cont\u2019d)\nLaceration of head of penis \nAssociated with heavy bleeding\nApply local pressure with sterile dressing.\nSkin of shaft or foreskin caught in zipper\nIf small segment of zipper is involved, try to unzip.\nIf long segment of zipper is involved, cut the zipper out of the pants with heavy scissors. External male genitalia (cont\u2019d)\nUrethral injuries are not uncommon.\nStraddle injuries, pelvic fractures, and penetrating wounds of the perineum\nImportant to know if patient can urinate and if there is blood in urine\nForeign bodies protruding from urethra will have to be surgically removed. External male genitalia (cont\u2019d)\nAvulsion of the skin of the scrotum may damage scrotal contents.\nPreserve avulsed skin in a moist sterile dressing.\nWrap scrotal contents or perineal area with a sterile moist compress.\nDirect blows to scrotum can result in rupture of a testicle or accumulation of blood around testes.\nApply ice to scrotal area. Female genitalia\nTreat lacerations and avulsions with moist, sterile compresses.\nUse local pressure to control bleeding.\nHold dressings in place with diaper-type bandage.\nDo not pack dressings into vagina. Female genitalia (cont\u2019d)\nLeave any foreign bodies in place after stabilizing with bandages.\nInjuries are painful but not life threatening. Rectal bleeding\nCommon complaint\nPossible causes include sexual assault, rectal foreign bodies, hemorrhoids, colitis, ulcers.",
        "Sexual assault and rape are common.": "Victims are generally women.\nSometimes men and children\nOften there is little you can do beyond providing compassion and transport.\nPatient may have sustained multisystem trauma and need treatment for shock. Do not examine genitalia unless obvious bleeding requires application of dressing.\nFollow appropriate procedures and protocol.\nShield patient from curious onlookers.\nDocument patient\u2019s history, assessment, treatment, and response to treatment. Follow crime scene policy of your EMS system.\nAdvise patient not to wash, bathe, shower, douche, urinate, or defecate until after examination.\nIf oral penetration occurred, advise patient not to eat, drink, brush the teeth, or use mouthwash until after examination.\nHandle patient\u2019s clothes as little as possible. Make sure EMT caring for patient is same gender as patient whenever possible.\nTreat medical injuries and provide privacy, support, and reassurance."
    },
    {
        "National EMS Education Standard Competencies": "Trauma\nApplies fundamental knowledge to provide basic emergency care and transportation based on assessment findings for an acutely injured patient. Chest Trauma\nRecognition and management of\nBlunt versus penetrating mechanisms\nOpen chest wound\nImpaled object Chest Trauma (cont\u2019d)\nPathophysiology, assessment, and management of\nBlunt versus penetrating mechanisms\nHemothorax Chest Trauma (cont\u2019d)\nPathophysiology, assessment, and management of:\nPneumothorax\nOpen\nSimple\nTension Chest Trauma (cont\u2019d)\nPathophysiology, assessment, and management of\nCardiac tamponade\nRib fractures\nFlail chest\nCommotio cordis",
        "Introduction": "Chest trauma causes more than 1.2 million emergency department visits each year.\nChest injuries can involve the heart, lungs, and great blood vessels.\nMay be the result of blunt trauma, penetrating trauma, or both Immediately treat injuries that interfere with normal breathing function.\nInternal bleeding can compress the lungs and heart.\nAir may collect in the chest, preventing lung expansion.",
        "Anatomy and Physiology": "Ventilation: the body\u2019s ability to move air in and out of the chest and lung tissue\nOxygenation: the process of delivering oxygen to the blood by diffusion from the alveoli following inhalation into the lungs\nInjuries may affect ventilation and/or oxygenation. Thoracic skin, muscle, and bones\nSimilarities to other regions\nAlso unique features to allow for ventilation, such as striated muscle FIGURE 30-1 A view of the anterior aspect of the chest\nshows the major organs beneath the surface. \u00a9 Jones & Bartlett Learning. The neurovascular bundle lies closely along the lowest margin of each rib.\nThe pleura covers each lung and the thoracic cavity.\nA small amount of pleural fluid between the parietal and visceral pleura allows the lungs to move freely against the inner chest wall during respiration. Vital organs, such as the heart, are protected by the ribs.\nConnected in the back to the vertebrae\nConnected in the front to the sternum FIGURE 30-2 The organs within the chest are protected by the ribs, which are connected in front (A) to the sternum and in back (B) to the vertebrae. A, B: \u00a9 Jones & Bartlett Learning. The mediastinum contains the heart, great vessels, esophagus, and trachea.\nThe diaphragm is a muscle that separates the thoracic cavity from the abdominal cavity.",
        "Mechanics of Ventilation": "The intercostal muscles and diaphragm contract during inhalation.\nThe intercostal muscles and the diaphragm relax during exhalation.\nThe body should not have to work to breathe when in a resting state. FIGURE 30-3 The mechanics of inhalation (A) and exhalation (B). A, B: \u00a9 Jones & Bartlett Learning. Patients with a spinal injury below C5 can still breathe from the diaphragm.\nPatients with a spinal injury above C3 may lose the ability to breathe. FIGURE 30-4 A patient who sustains a spinal cord injury below the level of C5 and is paralyzed can still breathe spontaneously because the phrenic nerves, which cause the diaphragm to contract, originate at the C3, C4, and C5 levels. \u00a9 Jones & Bartlett Learning. Tidal volume is the amount of air moved into or out of the lungs in a single breath.\nMinute ventilation is calculated by multiplying the tidal volume by the number of breaths per minute.\nChanging either number affects the amount of air moving through the system.",
        "Injuries of the Chest": "Two types: open and closed\nIn a closed chest injury, the skin is not broken.\nGenerally caused by blunt trauma FIGURE 30-5 Closed chest injuries usually result from blunt trauma, such as when a patient strikes the steering wheel or an airbag in a motor vehicle crash, or is struck by a falling object. A closed chest injury can occur even when a seat belt is worn. Courtesy of ED, Royal North Shore Hospital/NSW Institute of Trauma & Injury. Closed chest injury\nCan cause significant cardiac and pulmonary contusion\nIf the heart is damaged, it may not be able to refill with blood or blood may not be pumped with enough force out of the heart.\nLung tissue bruising can result in exponential loss of surface area.\nRib fractures may cause further damage. In an open chest injury, an object penetrates the chest wall itself.\nKnife, bullet, piece of metal, or broken end of fractured rib\nDo not attempt to move or remove the object. FIGURE 30-6 Open chest injuries can occur when\nan external object or the broken end of a fractured rib penetrates the chest wall. \u00a9 Jones & Bartlett Learning. Blunt trauma to the chest may cause:\nRib, sternum, and chest wall fractures\nBruising of the lungs and heart\nDamage to the aorta\nVital organs to be torn from their attachment in the chest cavity Signs and symptoms\nPain at the site of injury\nLocalized pain aggravated or increased with breathing\nBruising to the chest wall\nCrepitus with palpation of the chest\nPenetrating injury to the chest\nDyspnea Signs and symptoms (cont\u2019d)\nHemoptysis\nFailure of one or both sides of the chest to expand normally with inspiration\nRapid, weak pulse and low blood pressure\nCyanosis around the lips or fingernails\nDiminished breath sounds on one side\nLow oxygen saturation Chest injury patients often have rapid and shallow respirations.\nHurts to take a deep breath\nPatient may not be moving air.\nAuscultate multiple locations to assess for adequate breath sounds.",
        "Scene Size-up": "Scene safety and standard precautions\nEnsure the scene is safe for you, your partner, your patient, and bystanders.\nIf the area is a crime scene, do not disturb evidence if possible.\nRequest law enforcement for scenes involving violence.\nCall for ALS early. Mechanism of injury\nChest injuries are common in motor vehicle crashes, falls, industrial accidents, and assaults.\nDetermine the number of patients.\nConsider spinal immobilization.",
        "Primary Assessment": "Form a general impression.\nAddress life-threatening hemorrhage immediately. \nNote the patient\u2019s level of consciousness.\nPerform a rapid physical examination. Airway and breathing\nEnsure that the patient has a clear and patent airway.\nConsider early cervical spine stabilization if appropriate.\nAre jugular veins distended?\nIs breathing present and adequate?\nInspect for DCAP-BTLS. Airway and breathing (cont\u2019d)\nLook for equal expansion of the chest wall.\nCheck for paradoxical motion.\nApply occlusive dressings to all penetrating injuries.\nSupport ventilations. Airway and breathing (cont\u2019d)\nReassess the effectiveness of ventilatory support.\nBe alert for decreasing oxygen saturation.\nBe alert for impending tension pneumothorax. Circulation\nPulse rate and quality\nSkin color and temperature\nAddress life-threatening bleeding immediately, using direct pressure and a bulky dressing. Transport decision\nPriority patients are those with a problem with their XABCs.\nPay attention to subtle clues:\nAppearance of the skin\nLevel of consciousness\nA sense of impending doom in the patient",
        "History Taking Investigate the chief complaint.": "Further investigate the MOI.\nIdentify signs, symptoms, and pertinent negatives.\nSAMPLE history\nA basic evaluation should be completed.\nFocus on the MOI.",
        "Secondary Assessment": "Physical examinations\nFor an isolated injury, focus on:\nIsolated injury\nPatient\u2019s complaint\nBody region affected\nLocation and extent of injury\nAnterior and posterior aspects of the chest wall\nChanges in respirations Physical examinations (cont\u2019d)\nFor significant trauma likely affecting multiple systems, start with a rapid physical examination.\nUse DCAP-BTLS to determine the nature and extent of the injury. Vital signs\nAssess pulse, respirations, blood pressure, skin condition, oxygen saturation, and pupils.\nReevaluate every 5 minutes or less.\nPulse and respiratory rates may decrease in later stages of the chest injury.",
        "Reassessment": "Repeat the primary assessment.\nReassess the chief complaint.\nReevaluate:\nAirway\nBreathing\nPulse\nPerfusion\nBleeding Interventions\nReassess vital signs and observe trends.\nProvide appropriate spinal stabilization when indicated.\nMaintain an open airway.\nControl significant, visible bleeding.\nPlace an occlusive dressing over penetrating trauma to the chest wall. Interventions (cont\u2019d)\nProvide aggressive treatment for shock and rapid transport.\nDo not delay transport to complete non\u2013life-saving treatments.\nCommunicate all relevant information to the staff at the receiving hospital.",
        "Commonly called a collapsed lung": "Accumulation of air in the pleural space\nBlood passing through the collapsed portion of the lung is not oxygenated.\nYou may hear diminished, absent, or abnormal breath sounds. FIGURE 30-8 Pneumothorax occurs when air leaks into\nthe space between the pleural surfaces from an opening in\nthe chest wall or the surface of the lung. Air in the pleural\nspace causes the lung to collapse. \u00a9 Jones & Bartlett Learning. Open chest wound\nOften called an open pneumothorax or a sucking chest wound\nWounds must be rapidly sealed with an occlusive dressing. \nA flutter valve is a one-way valve.\nCarefully monitor the patient for tension pneumothorax. FIGURE 30-9 With a sucking chest wound, air passes\nfrom the outside into the pleural space and back out with\neach breath, creating a sucking sound \u00a9 Jones & Bartlett Learning. Simple pneumothorax\nDoes not result in major changes in the patient\u2019s cardiac physiology\nCommonly due to blunt trauma that results in fractured ribs\nCan often worsen, deteriorate into tension pneumothorax, or develop complications Tension pneumothorax\nResults from ongoing air accumulation in the pleural space\nIncreased pressure in the chest:\nCauses complete collapse of the unaffected lung\nMediastinum is pushed into the opposite pleural cavity.\nCommonly caused by a blunt injury where a fractured rib lacerates a lung or bronchus FIGURE 30-12 A tension pneumothorax can develop if a penetrating chest wound is bandaged tightly and air from a damaged lung cannot escape. The air then accumulates in the pleural space, eventually causing compression of the heart and great vessels. If a dressing sealed on four sides with no vent is used, monitor for signs of tension pneumothorax developing and prepare to vent one side of the dressing. \u00a9 Jones & Bartlett Learning.",
        "Blood collects in the pleural space from bleeding around the rib cage or from a lung or great vessel. FIGURE 30-13 A. A hemothorax is a collection of blood in the pleural space produced by bleeding within the chest. B. When both blood and air are present, the condition is a hemopneumothorax. A, B: \u00a9 Jones & Bartlett Learning. Signs and symptoms": "Shock without any obvious external bleeding or apparent reason for shock\nDecreased breath sounds on the affected side\nPrehospital treatment\nRapid transport\nHemopneumothorax: the presence of air and blood in the pleural space",
        "Protective membrane (pericardium) around the heart fills with blood or fluid.": "The heart cannot pump an adequate amount of blood. FIGURE 30-14 Cardiac tamponade, also known as pericardial tamponade,\nis a potentially fatal condition in which fluid or blood builds up within\nthe pericardial sac, causing compression of the heart\u2019s chambers and\ndramatically impairing its ability to pump blood to the body. \u00a9 Jones & Bartlett Learning. Signs and symptoms\nBeck triad\nAltered mental status\nPrehospital treatment\nSupport ventilations\nRapidly transport",
        "Rib Fractures": "Common, particularly in older people\nA fracture of one of the upper four ribs is a sign of a substantial MOI.\nA fractured rib may cause a pneumothorax, hemothorax, or hemopneumothorax. Signs and symptoms\nLocalized tenderness and pain when breathing\nRapid, shallow respirations\nPatient holding the affected portion of the rib cage\nPrehospital treatment includes supplemental oxygen.",
        "Caused by compound rib fractures that detach a segment of the chest wall": "Detached portion moves opposite of normal FIGURE 30-15 When two or more adjacent ribs are fractured in two or more places, a flail chest results. A flail segment will move paradoxically when the patient breathes. \u00a9 Jones & Bartlett Learning. Prehospital treatment\nMaintain the airway.\nProvide respiratory support, if needed.\nGive supplemental oxygen.\nPerform ongoing assessments for complications. Treatment may include positive pressure ventilation with a bag-mask device.\nRestricting chest wall movement is no longer recommended. \nFlail chest may indicate serious internal damage or spinal injury.",
        "Other Chest Injuries": "Pulmonary contusion\nShould always be suspected in a patient with a flail chest\nPulmonary alveoli become filled with blood, leading to hypoxia.\nPrehospital treatment\nSupplemental oxygen and positive pressure ventilation as needed Other fractures\nSternal fractures\nCreate an increased index of suspicion for organ injury\nClavicle fractures\nPossible damage to neurovascular bundle\nSuspect upper rib fractures in medial clavicle fractures.\nBe alert to pneumothorax development. Traumatic asphyxia\nCharacterized by distended neck veins, cyanosis in the face and neck, and hemorrhage in the sclera of the eye FIGURE 30-16 Traumatic asphyxia. \u00a9 Charles Stewart MD, EMDM MPH. Traumatic asphyxia (cont\u2019d)\nSuggests an underlying injury to the heart and possibly a pulmonary contusion\nPrehospital treatment\nVentilatory support and supplemental oxygen\nMonitor vital signs during immediate transport. Blunt myocardial injury\nBruising of the heart muscle\nThe heart may be unable to maintain adequate blood pressure.\nSigns and symptoms\nIrregular pulse rate\nChest pain or discomfort Blunt myocardial injury (cont\u2019d)\nSuspect it in all cases of severe blunt injury to the chest.\nPrehospital treatment\nCarefully monitor the pulse.\nNote changes in blood pressure.\nProvide supplemental oxygen and transport immediately. Commotio cordis\nInjury caused by a sudden, direct blow to the chest during a critical portion of the heartbeat\nMay result in immediate cardiac arrest\nVentricular fibrillation is often responsive to defibrillation and early initiation of CPR. Laceration of the great vessels\nMay result in rapidly fatal hemorrhage\nPrehospital treatment\nCardiopulmonary resuscitation \nVentilatory support and supplemental oxygen, if needed\nImmediate transport\nBe alert for shock.\nMonitor for changes in baseline vital signs."
    },
    {
        "National EMS Education Standard Competencies": "Trauma\nApplies fundamental knowledge to provide basic emergency care and transportation based on assessment findings for an acutely injured patient. Bleeding\nRecognition and management of\nBleeding\nPathophysiology, assessment, and management of\nBleeding Pathophysiology\nApplies fundamental knowledge of the pathophysiology of respiration and perfusion to patient assessment and management.",
        "Introduction Important to be able to:": "Recognize bleeding.\nUnderstand how bleeding affects the body. \nBleeding can be external or internal.\nBleeding can cause weakness, shock, and death.",
        "Anatomy and Physiology of the Cardiovascular System": "The cardiovascular system circulates blood to cells and tissues.\nDelivers oxygen and nutrients\nCarries away metabolic waste products\nResponsible for supplying and maintaining adequate blood flow Three parts\nPump (heart)\nContainer (blood vessels)\nFluid (blood and body fluids) FIGURE 26-1 The cardiovascular system includes the heart, arteries, veins, and interconnecting capillaries. \u00a9 Jones & Bartlett Learning.",
        "Needs a rich and well-distributed blood supply": "Works as two paired pumps\nUpper chamber (atrium)\nLower chamber (ventricle)\nBlood leaves each chamber through a one-way valve. FIGURE 26-2 A. The right side of the heart circulates blood from the body to the lungs. B. The left side of the heart circulates oxygen-rich blood from the lungs to the rest of the body. It is the more muscular of the two pumps because it must pump blood into the aorta and arteries in order to reach all cells of the body. A, B: \u00a9 Jones & Bartlett Learning.",
        "Blood Vessels and Blood": "Arteries\nCarry blood away from the heart\nArterioles\nSmaller vessels that connect the arteries and capillaries\nCapillaries\nPass among all the cells and link arterioles and venules Venules\nVery small, thin-walled vessels that empty into the veins\nVeins\nCarry blood from the tissues to the heart Oxygen and nutrients pass from the capillaries into the cells.\nWaste and carbon dioxide diffuse into the capillaries. FIGURE 26-3 Oxygen and nutrients pass easily from the capillaries into the cells, and waste and carbon dioxide diffuse from the cells into the capillaries (top). Oxygen and carbon dioxide pass freely between the lungs and capillaries (bottom). \u00a9 Jones & Bartlett Learning. Blood contains\nRed blood cells\nResponsible for the transportation of oxygen to the cells and carbon dioxide away from the cells to the lungs Blood contains (cont\u2019d)\nWhite blood cells\nResponsible for fighting infection\nPlatelets\nResponsible for forming blood clots\nPlasma FIGURE 26-4 The microscopic appearance of the three major elements in blood: red blood cells, white blood cells, and platelets. \u00a9 Donna Beer Stolz, Ph.D., Center for Biologic Imaging, University of Pittsburgh Medical School. Blood clot formation depends on:\nBlood stasis\nChanges in the blood vessel walls \nBlood\u2019s ability to clot  \nWhen tissues are injured, platelets begin to collect at the site of injury.\nRed blood cells to become sticky and clump together.",
        "Autonomic Nervous System Monitors the body\u2019s needs": "Adjusts blood flow \nAutomatically redirects blood away from other organs to the heart, brain, lungs, and kidneys in an emergency\nAdapts to maintain homeostasis and perfusion",
        "Pathophysiology and Perfusion": "Perfusion is the circulation of blood within an organ or tissue to meet the cells\u2019 needs for oxygen, nutrients, and waste removal. FIGURE 26-5 Perfusion occurs when blood circulates\nthrough tissues or an organ to provide the necessary\noxygen and nutrients and remove waste products. \u00a9 Jones & Bartlett Learning. All organs and organ systems depend on adequate perfusion to function properly.\nDeath of an organ system can quickly lead to death of the patient.\nEmergency care supports adequate perfusion until the patient arrives at the hospital.\nThe heart requires a constant supply of blood.",
        "Speed of blood flow": "Fast enough to maintain circulation\nSlow enough to allow cells to exchange oxygen and nutrients for carbon dioxide and waste\nSome tissues need a constant supply of blood, while others can survive with very little.",
        "External Bleeding Hemorrhage means bleeding.": "External bleeding is visible hemorrhage.",
        "Significance of External Bleeding": "With serious external bleeding, it may be difficult to tell the amount of blood loss.\nBlood looks different on different surfaces.\nEstimate the amount of external blood loss. \nBody will not tolerate a blood loss greater than 20% of blood volume. Changes in vital signs may occur with significant blood loss.\nIncrease in heart rate\nIncrease in respiratory rate\nDecrease in blood pressure How well people compensate for blood loss is related to how rapidly they bleed.\nAn adult can comfortably donate 1 unit (500 mL) of blood over 15 to 20 minutes.\nIf a similar blood loss occurs in a much shorter time, the person may rapidly develop symptoms of hypovolemic shock.\nConsider age and preexisting health.",
        "Characteristics of External Bleeding": "Serious conditions with bleeding:\nSignificant MOI\nPatient has a poor general appearance and is calm.\nSigns and symptoms of shock\nSignificant blood loss\nRapid blood loss \nUncontrollable bleeding Arterial bleeding\nPressure causes blood to spurt and makes bleeding difficult to control.\nTypically brighter red and spurts in time with the pulse\nVenous bleeding\nDark red, flows slowly or rapidly depending on the size of the vein\nDoes not spurt and is easier to manage Capillary bleeding\nBleeding from damaged capillary vessels\nDark red, oozes steadily but slowly FIGURE 26-7 A. Bleeding from capillary vessels is\ndark red and oozes from the wound slowly but steadily.\nB. Venous bleeding is darker than arterial bleeding and\nflows steadily. C. Arterial bleeding is characteristically\nbright red and spurts in time with the pulse. A, B, C: \u00a9 Jones & Bartlett Learning.",
        "Clotting Bleeding tends to stop rather quickly, within about 10 minutes.": "When skin is broken, blood flows rapidly.\nThe cut end of the vessel begins to narrow, reducing the amount of bleeding.\nThen a clot forms.\nBleeding will not stop if a clot does not form.",
        "Hemophilia Patient lacks blood-clotting factors.": "Bleeding may occur spontaneously.\nAll injuries, no matter how trivial, are potentially serious.\nPatients should be transported immediately.",
        "Can be very serious because it is not easy to detect immediately": "Injury or damage to internal organs commonly results in extensive internal bleeding.\nCan cause hypovolemic shock Possible conditions causing internal bleeding:\nStomach ulcer \nLacerated liver \nRuptured spleen \nBroken bones",
        "MOI for Internal Bleeding": "High-energy MOI\nShould increase your index of suspicion for serious unseen injuries\nInternal bleeding is possible whenever the MOI suggests that severe forces affected the body.\nBlunt trauma\nPenetrating trauma Signs of injury (DCAP-BTLS)\nDeformities\nContusions\nAbrasions\nPunctures/penetrations\nBurns\nTenderness\nLacerations\nSwelling",
        "NOI for Internal Bleeding Internal bleeding is not always caused by trauma.": "Nontraumatic causes include:\nBleeding ulcers\nBleeding from colon\nRuptured ectopic pregnancy\nAneurysms",
        "Signs and Symptoms of Internal Bleeding": "Pain (most common)\nSwelling in the area of bleeding\nDistention\nDyspnea, tachycardia, hypotension\nHematoma\nBruising Bleeding from any body opening\nHematemesis\nMelena\nPain, tenderness, bruising, guarding, or swelling\nBroken ribs\nBruises over the lower part of the chest\nRigid, distended abdomen Hypoperfusion\nChange in mental status\nWeakness, faintness, or dizziness on standing\nChanges in skin color or pallor (pale skin)\nLater signs of hypoperfusion:\nTachycardia\nWeakness, fainting, or dizziness at rest\nThirst, nausea and vomiting\nCold, moist (clammy) skin Later signs of hypoperfusion (cont\u2019d):\nShallow, rapid breathing\nDull eyes, slightly dilated pupils\nCapillary refill of more than 2 seconds in infants and children\nWeak, rapid (thready) pulse\nDecreasing blood pressure\nAltered level of consciousness",
        "Scene Size-up": "Scene safety\nBe alert to potential hazards.\nIn violent incidents, make sure the police are on the scene.\nFollow standard precautions. Mechanism of injury/nature of illness\nDetermine the NOI or MOI.\nConsider the need for spinal immobilization and additional resources.\nConsider environmental factors such as weather.",
        "Primary Assessment": "Do not be distracted from identifying life threats.\nForm a general impression.\nNote important indicators of the patient\u2019s condition.\nBe aware of obvious signs of injury.\nDetermine gender and age. Perform a rapid exam. \nLook for life threats and treat them as you find them. \nIf the patient has obvious, life-threatening external bleeding, address it first.\nAssess skin color.\nDetermine level of consciousness. Transport decision\nAssessment of XABCs and life threats will determine the transport priority.\nSigns that imply rapid transport:\nTachycardia or tachypnea\t\nLow blood pressure\nWeak pulse\nClammy skin",
        "Airway and breathing": "Consider the need for spinal stabilization.\nEnsure a patent airway.\nLook for adequate breathing.\nCheck for breath sounds.\nProvide high-flow oxygen or assist ventilations with a bag-mask device or nonrebreathing mask.\nInsert an oropharyngeal airway if the patient is unconscious.",
        "Circulation": "Assess pulse rate and quality.\nDetermine skin condition, color, and temperature.\nCheck capillary refill time.\nControl external bleeding.\nTreat for shock.",
        "History Taking": "Investigate the chief complaint.\nLook for signs and symptoms of other injuries due to the MOI and/or NOI.\nNote obvious signs of internal bleeding.\nAssess the entire patient. SAMPLE history\nAsk the patient about blood-thinning medications.\nIf the patient is unresponsive, obtain history from medical alert tags or bystanders.\nLook for signs and symptoms of shock.\nDetermine the amount of blood loss.",
        "Secondary Assessment Assess all areas for DCAP-BTLS.": "Record vital signs.\nAttach appropriate monitoring devices.\nWith a critically injured patient or a short transport time, there may not be time to conduct a secondary assessment.",
        "Reassessment": "Reassess the patient in areas that showed abnormal findings.\nSigns and symptoms of internal bleeding are often slow to present.\nReassess an unstable patient every 5 minutes and a stable patient every 15 minutes. Interventions\nProvide high-flow oxygen.\nControl external bleeding. \nProvide treatment for shock and transport rapidly.\nDo not delay transport of a patient to complete an assessment. Communication and documentation\nRecognize, estimate, and report the amount of blood loss and how rapidly or over what period of time it occurred.\nCommunicate all relevant information to the staff at the receiving hospital.\nDocument all injuries, the care provided, and the patient\u2019s response.",
        "Emergency Medical Care for External Bleeding": "Follow standard precautions.\nWear gloves, eye protection, and possibly a mask or gown.\nMake sure the patient has an open airway and is breathing adequately.\nProvide high-flow oxygen.\nControl obvious, life-threatening bleeding as quickly as possible. Several methods are available to control external bleeding.\nDirect, even pressure and elevation\nPressure dressings and/or splints\nTourniquets\nHemostatic dressing\nWound packing",
        "Direct Pressure Most common and effective way to control external bleeding": "Pressure stops the flow of blood and permits normal coagulation to occur.\nApply pressure with your gloved fingertip or hand over the top of a sterile dressing.\nHold uninterrupted pressure for at least 5 minutes.",
        "Pressure Dressing Firmly wrap a sterile, self-adhering roller bandage around the entire wound.": "Stretch the band tight enough to control bleeding.\nDo not remove a dressing until a physician has evaluated the patient.\nA tourniquet is useful if the bleeding cannot be managed with direct pressure.",
        "Hemostatic Agents Gauze can be packed into larger wounds when direct pressure is inadequate, or application of a tourniquet is not possible.": "A hemostatic dressing is impregnated with a chemical compound that slows or stops bleeding by promoting clot formation.",
        "Useful if a patient has substantial bleeding from an extremity injury": "Several types of commercial tourniquets are available. Junctional tourniquets allow for compression of life-threatening bleeding in areas where standard tourniquet application is not possible.\nMay be indicated for severe hemorrhage at the junction of the torso with the arms and legs.",
        "Air splints": "Soft splints or pressure splints\nCan control internal or external bleeding associated with severe injuries FIGURE 26-11 Air splints can also be used to control\nbleeding because they act as a pressure bandage for the\nentire extremity. They are not as effective as tourniquets,\nhowever, and should never be used when a tourniquet is\notherwise indicated. \u00a9 Jones & Bartlett Learning. Courtesy of MIEMSS. Air splints (cont\u2019d)\nImmobilize fractures\nAct like a pressure dressing\nUse only approved, clean, or disposable valve stems. Pelvic binder\nA type of splint that may be indicated for a suspected closed unstable pelvic fracture\nHelps to control internal bleeding",
        "Bleeding From the Nose, Ears, and Mouth": "Several conditions\nSkull fracture\nFacial injuries\nSinusitis, infections, use and abuse of nose drops, dried or cracked nasal mucosa\nHigh blood pressure\nCoagulation disorders\nDigital trauma\nCancer Epistaxis (nosebleed) is a common emergency.\nOccasionally it can cause enough blood loss to send a patient into shock.\nCan usually be controlled by pinching the nostrils together Bleeding from the nose or ears following a head injury:\nMay indicate a skull fracture\nMay be difficult to control\nDo not attempt to stop blood flow.\nLoosely cover the bleeding site with a sterile gauze pad.\nApply light compression with a dressing. A target or halo-shaped stain may occur on the dressing if blood or drainage contains cerebrospinal fluid. FIGURE 26-14 When cerebrospinal fluid is present in blood or drainage, a stain in the shape of a target or halo will appear. Courtesy of Rhonda Hunt.",
        "Emergency Medical Care for Internal Bleeding Usually requires surgery or other hospital procedures": "Keep the patient calm, reassured, and as still and quiet as possible.\nProvide high-flow oxygen.\nMaintain body temperature.\nSplint the injured extremity (air splint)."
    },
    {
        "National EMS Education Standard Competencies": "Trauma\nApplies fundamental knowledge to provide basic emergency care and transportation based on assessment findings for an acutely injured patient. Orthopaedic Trauma\nRecognition and management of\nOpen fractures\nClosed fractures\nDislocations\nAmputations Pathophysiology, assessment, and management of\nUpper and lower extremity orthopaedic trauma\nOpen fractures\nClosed fractures\nDislocations\nSprains/strains\nPelvic fractures\nAmputations/replantation Medicine\nApplies fundamental knowledge to provide basic emergency care and transportation based on assessment findings for an acutely ill patient. Nontraumatic Musculoskeletal Disorders\nAnatomy, physiology, pathophysiology, assessment, and management of\nNontraumatic fractures",
        "Introduction": "The musculoskeletal system provides:\nForm \nUpright posture\nMovement\nSystem also protects vital internal organs.\nBones, muscles, tendons, cartilage, and ligaments are still at risk. Musculoskeletal injuries are among the most common reasons why patients seek medical attention.\nOften easily identified because of associated pain, swelling, and deformity\nOften result in short- or long-term disability",
        "Anatomy and Physiology of the Musculoskeletal System": "Three types of muscles: skeletal, smooth, and cardiac FIGURE 32-1 For musculoskeletal injuries, the major muscle type involved is skeletal muscle. \u00a9 Jones & Bartlett Learning. Skeletal muscle attaches to the bones and usually crosses at least one joint.\nAlso called voluntary muscle \nMakes up the largest portion of the body\u2019s muscle mass FIGURE 32-2 Skeletal muscles are supplied by arteries,\nveins, and nerves that bring oxygen and nutrients, carry away waste products, and conduct nervous stimuli. \u00a9 Jones & Bartlett Learning.",
        "All skeletal muscles are supplied with arteries, veins, and nerves.": "Skeletal muscle tissue is directly attached to the bone by tendons.",
        "Smooth muscle performs much of the automatic work of the body.": "Contracts and relaxes to control the movement of the contents within tubular structures FIGURE 32-3 Smooth muscle is found in the walls of most tubular structures in the body. These muscles contract and relax to control the movement of the contents within these structures. \u00a9 Jones & Bartlett Learning.",
        "Cardiac muscle is a specially adapted involuntary muscle with its own regulatory system.": "Cardiac muscle is a specially adapted involuntary muscle with its own regulatory system.",
        "Gives us our recognizable human form": "Protects our vital organs\nAllows us to move\nMade up of approximately 206 bones\nProduces blood cells (in the bone marrow)\nServes as a reservoir for minerals and electrolytes FIGURE 32-4 The human skeleton, consisting of\napproximately 206 bones, gives us our form and protects our vital organs. \u00a9 Jones & Bartlett Learning. The skull protects the brain.\nThe thoracic cage protects the heart, lungs, and great vessels.\nThe pectoral girdle consists of two scapulae and two clavicles. FIGURE 32-5 The pectoral girdle. A. Anterior view, including the clavicle. B. Posterior view, including the scapula. A, B: \u00a9 Jones & Bartlett Learning. The upper extremity extends from the shoulder to the fingertips.\nComposed of the upper arm (humerus), elbow, and forearm (radius and ulna) FIGURE 32-6 The anatomy of the arm. \u00a9 Jones & Bartlett Learning. The hand contains three sets of bones:\nWrist bones (carpals)\nHand bones (metacarpals)\nFinger bones (phalanges) FIGURE 32-7 The anatomy of the wrist and hand. \u00a9 Jones & Bartlett Learning. The pelvis supports the body weight and protects the structures within the pelvis: the bladder, rectum, and female reproductive organs.\nPelvic girdle is formed by the ischium, ilium, and pubis.\nBones are fused to form the innominate (hip) bone. The lower extremity consists of the bones of the thigh, leg, and foot.\nFemur (thigh bone)\nFemoral head\nTibia and fibula\nPatella (kneecap) FIGURE 32-8 The bones of the thigh, leg, and foot. \u00a9 Jones & Bartlett Learning. The foot consists of three classes of bones:\nAnkle bones (tarsals)\nFoot bones (metatarsals)\nToe bones (phalanges) FIGURE 32-9 The bones of the foot and ankle. \u00a9 Jones & Bartlett Learning. The bones of the skeleton provide a framework to which the muscles and tendons are attached.\nA joint is formed wherever two bones come into contact.\nHeld together in a tough fibrous capsule\nLubricated by synovial fluid\nAllows motion",
        "Mechanism of Injury Significant force is generally required to cause fractures and dislocations.": "Direct blows\nIndirect forces\nTwisting forces\nHigh-energy forces",
        "A break in the continuity of the bone": "Classified as either closed or open\nDetermine whether the overlying skin is damaged.\nTreat any injury that breaks the skin as a possible open fracture. Fractures are described by whether the bone is moved from its normal position.\nA nondisplaced fracture is a simple crack of the bone.\nA displaced fracture produces actual deformity or distortion of the limb. FIGURE 32-15 Special terms to describe fractures.\nA. Greenstick fracture. B. Oblique fracture. C. Pathologic fracture. D. Incomplete fracture. A-D: \u00a9 Jones & Bartlett Learning. Comminuted\nA fracture in which the bone is broken into more than two fragments\nEpiphyseal\nA fracture in the growth section of a child\u2019s bone\nGreenstick\nAn incomplete fracture that passes only partway through the shaft of a bone Incomplete\nA fracture that does not run completely through the bone\nOblique\nA fracture in which the bone is broken at an angle across the bone\nPathologic\nA fracture of weakened or diseased bone Spiral\nA fracture caused by a twisting force, causing an oblique fracture around and through the bone\nTransverse\nA fracture that occurs straight across the bone Suspect a fracture if one or more of the following signs are present:\nDeformity\nTenderness\nGuarding\nSwelling Figure 32-18 FIGURE 32-16 Obvious deformity, shortening, rotation, or angulation should increase your index of suspicion for a fracture. \u00a9 Charles Stewart MD, EMDM MPH. FIGURE 32-18 Swelling that occurs in association with a fracture can often mask deformity of the limb. \u00a9 Dr. P. Marazzi/Science Source. Signs of fractures (cont\u2019d)\nBruising\nCrepitus\nFalse motion\nExposed fragments\nPain\nLocked joint FIGURE 32-19 Fractures almost always have associated\nbruising into the surrounding soft tissue. \u00a9 fotokostic/iStockphoto.",
        "Dislocations": "A disruption of a joint in which the bone ends are no longer in contact\nSometimes a dislocated joint will spontaneously reduce.\nConfirm the dislocation with the patient history.\nA dislocation that does not reduce is a serious problem. Signs and symptoms\nMarked deformity\nSwelling\nPain that is aggravated by any attempt at movement\nTenderness on palpation\nLoss of normal joint motion\nNumbness or impaired circulation",
        "Occur when a joint is twisted or stretched beyond its normal range of motion.": "Can range from mild to severe\nMost vulnerable joints are the knees, shoulders, and ankles\nSevere deformity does not typically occur. Signs and symptoms\nGuarding\nSwelling and ecchymosis\nPain\nInstability of the joint FIGURE 32-23 Sprains often occur in the knee or\nankle and are characterized by swelling, bruising, point tenderness, pain, and joint instability. \u00a9 Sean Gladwell/Dreamstime.com.",
        "Strain A stretching or tearing of the muscle.": "Causes pain, swelling, and bruising of the soft tissues in the area \nOften no deformity is present and only minor swelling is noted at the site of the injury.",
        "Amputations An amputation is an injury in which an extremity is completely severed from the body.": "Can damage every aspect of the musculoskeletal system Surgeons can occasionally reattach amputated parts.\nMake sure to immobilize the part with bulky compression dressings.\nDo not sever any partial amputations.\nControl any bleeding from the stump.\nIf bleeding is severe, quickly apply a tourniquet. With a complete amputation, wrap the clean part in a sterile dressing, and place it in a plastic bag.\nFollow local protocols regarding how to preserve amputated parts. \nPut the bag in a cool container filled with ice.\nThe goal is to keep the part cool without allowing it to freeze or develop frostbite.",
        "Complications": "Orthopaedic injuries can also lead to systemic changes or illnesses.\nLikelihood of having a complication is related to the:\nStrength of the force that caused the injury\nInjury\u2019s location\nPatient\u2019s overall health To prevent contamination following an open fracture:\nBrush away any debris on the skin.\nDo not enter or probe the fracture site.\nLong-term disability is one of the most devastating consequences of an orthopaedic injury. You can help reduce the risk or duration of long-term disability by:\nPreventing further injury\nReducing the risk of wound infection\nMinimizing pain by the use of cold and analgesia\nTransporting patients to an appropriate medical facility",
        "Assessing the Severity of Injury The Golden Hour is critical for life and for preserving limb viability.": "Prolonged hypoperfusion can cause significant damage.\nAny suspected open fracture or vascular injury is a critical emergency.\nMost injuries are not critical.",
        "Patient Assessment Always look at the big picture.": "Distinguish mild injuries from severe injuries.\nSevere injuries may compromise neurovascular function, which could be limb threatening.",
        "Scene Size-up": "Scene safety\nIdentify the forces associated with the MOI.\nUse standard precautions.\nConsider that there may be hidden bleeding.\nEvaluate the need for additional support. Mechanism of injury/nature of illness\nLook for indicators of the MOI.\nBe alert for both primary and secondary injuries.\nConsider what injuries the MOI would lead you to expect.",
        "Primary Assessment": "Focus on identifying and managing life threats.\nTreat patient according to level of consciousness and XABCs.\nAddress bleeding and treat for shock.\nCheck for responsiveness using the AVPU scale.\nAsk about the chief complaint. Treat patient (cont\u2019d)\nAdminister high-flow oxygen to all patients whose level of consciousness is less than alert and oriented.\nAsk about the MOI.\nIf there was significant trauma, the musculoskeletal injuries may be a lower priority. Airway and breathing\nFractures and sprains usually do not create airway and breathing problems.\nEvaluate the chief complaint and MOI. Circulation\nDetermine whether the patient has a pulse, has adequate perfusion, or is bleeding.\nIf the skin is pale, cool, or clammy and capillary refill time is slow, treat for shock.\nMaintain a normal body temperature. Transport decision\nProvide rapid transport if the patient has an airway or breathing problem or significant bleeding.\nA patient who has a significant MOI but whose condition appears stable should also be transported promptly.\nPatients with a simple MOI may be further assessed on scene.",
        "History Taking Obtain a medical history and be alert for injury-specific signs and symptoms and any pertinent negatives.": "Obtain a SAMPLE history for all trauma patients.\nOPQRST is too lengthy when ABCs require immediate attention.",
        "Physical examinations": "If significant trauma has occurred, start with a secondary assessment of the entire body.\nBegin with the head and work systematically toward the feet.\nUse DCAP-BTLS to assess the musculoskeletal system. Physical examinations (cont\u2019d)\nWhen lacerations are present in an extremity, consider an open fracture.\nAny injury or deformity of the bone may be associated with vessel or nerve injury.\nAssess neurovascular function. \nUse the 6 Ps of musculoskeletal assessment.\nObtain a baseline set of vital signs",
        "Reassessment": "Repeat the primary assessment.\nEvery 5 minutes for an unstable patient\nEvery 15 minutes for a stable patient\nAssess the overall condition, stabilize the XABCs, and control any serious bleeding.\nIn a critically injured patient, secure the patient to a long backboard and transport. If the patient has no life-threatening injuries, take extra time at the scene to stabilize his or her condition.\nThe main goal is stabilization in the most comfortable position that allows for maintenance of good circulation distal to the injury. Communication and documentation\nInclude a description of the problems found during your assessment.\nReport problems with the ABCs, open fractures, and compromised circulation.\nDocument complete descriptions of injuries and the MOIs associated with them.",
        "Emergency Medical Care Perform a primary assessment.": "Stabilize the patient\u2019s XABCs.\nPerform a secondary assessment of either the entire body or the specific area of injury. \nFollow standard precautions.\nBe alert for internal bleeding.",
        "A splint is a flexible or rigid device that is used to protect and maintain the position of an injured extremity.": "Splint all fractures, dislocations, and sprains before moving the patient, unless he or she is in immediate danger.\nSplinting reduces pain and makes it easier to transfer and transport the patient. Splinting will help to prevent:\nFurther damage to muscles, the spinal cord, peripheral nerves, and blood vessels\nLaceration of the skin\nRestriction of distal blood flow\nExcessive bleeding of the tissues\nIncreased pain\nParalysis of extremities General principles of splinting\nRemove clothing from the area.\nNote and record the patient\u2019s neurovascular status.\nCover open wounds with a dry, sterile dressing.\nDo not move the patient before splinting an extremity unless there is danger.\nStabilize the joints. General principles of splinting (cont\u2019d)\nPad all rigid splints.\nMaintain manual stabilization.\nIf you encounter resistance, splint the limb in its deformed position.\nImmobilize all suspected spinal injuries in a neutral, in-line position.\nWhen in doubt, splint.",
        "Rigid Splints": "Made from firm material\nApplied to the sides, front, and/or back of an injured extremity\nPrevent motion at the injury site\nTake two EMTs to apply Two situations in which you must splint the limb in the position of deformity:\nWhen the deformity is severe\nWhen you encounter resistance or extreme pain when applying gentle traction to the fracture of a shaft of a long bone",
        "Formable Splints Most likely to use structural aluminum (SAM) splints and vacuum splints": "Other splints:\nAir splints\nPillow splints\nSling and swathe bandages\nVacuum splints",
        "Pelvic Binder Used to splint the bony pelvis to reduce hemorrhage from bone ends, venous disruption, and pain": "Meant to provide temporary stabilization",
        "Hazards of Improper Splinting Compressions of nerves, tissues, and blood vessels": "Delay in transport of a patient with a life-threatening injury\nReduction of distal circulation\nAggravation of the injury\nInjury to tissue, nerves, blood vessels, or muscles",
        "Transportation Very few musculoskeletal injuries justify the use of excessive speed during transport.": "A patient with a pulseless limb must be given a higher priority.\nIf the treatment facility is an hour or more away, transport by helicopter or immediate ground transportation.",
        "Injuries of the Clavicle and Scapula": "The clavicle is one of the most commonly fractured bones in the body.\nOccur commonly in children\nA patient will report pain in the shoulder and hold the arm across the front of the body.\nSwelling and point tenderness occur over the clavicle. Fractures of the scapula occur much less frequently because the bone is well protected by many large muscles.\nAlmost always the result of a forceful, direct blow to the back\nThe associated chest injuries pose the greatest threat of long-term disability. Acromioclavicular joint is frequently separated during sports.\nThese fractures can be splinted effectively with a sling and swathe. FIGURE 32-31 A. Apply a sling so that the knot is tied to one side of the neck. B. Bind the arm to the chest wall with a swathe so that the arm cannot swing freely. Leave the patient\u2019s fingers exposed so that you can assess distal circulation. A, B: \u00a9 Jones & Bartlett Learning. Courtesy of MIEMSS.",
        "Dislocation of the Shoulder The humeral head most commonly dislocates anteriorly.": "Shoulder dislocations are very painful.\nStabilization is difficult because any attempt to bring the arm in toward the chest wall produces pain.\nSplint the joint in whatever position is more comfortable for the patient.",
        "Fracture of the Humerus Occur either proximally, in the midshaft, or distally at the elbow": "Consider applying traction to realign the fracture fragments before splinting them.\nSplint the arm with a sling and swathe.",
        "Different types of injuries are difficult to distinguish without x-ray examinations.": "Fracture of the distal humerus\nCommon in children\nFracture fragments rotate significantly, producing deformity and causing injuries to nearby vessels and nerves. Dislocation of the elbow\nTypically occurs in athletes\nThe ulna and radius are most often displaced posteriorly. FIGURE 32-37 Posterior dislocation of the elbow makes the olecranon process of the ulna much more prominent. \u00a9 JUNG YEON-JE/AFP/Getty Images. Fracture of olecranon process of ulna\nCan result from direct or indirect forces\nOften associated with lacerations and abrasions\nPatient will be unable to extend the elbow. Fractures of the radial head\nOften missed during diagnosis\nGenerally occurs as a result of a fall on an outstretched arm or a direct blow to the lateral aspect of the elbow\nAttempts to rotate the elbow or wrist cause discomfort. Care of elbow injuries\nAll elbow injuries are potentially serious and require careful management.\nAlways assess distal neurovascular functions periodically.\nProvide prompt transport for all patients with impaired distal circulation.",
        "Fractures of the Forearm Common in people of all age groups": "Seen most often in children and elderly\nUsually the radius and the ulna break at the same time.\nTo stabilize fractures, you can use a padded board, air, vacuum, or pillow splint.",
        "Injuries of the Wrist and Hand Must be confirmed by x-ray exams": "Dislocations are usually associated with a fracture.\nIsolated, nondisplaced fracture of a carpal bone is common.\nAny questionable wrist injury should be splinted and evaluated in the ED.",
        "Fractures of the Pelvis": "Often results from direct compression in the form of a heavy blow\nMay be accompanied by life-threatening loss of blood\nOpen fractures are quite uncommon.\nBone fragments can lacerate the rectum, vagina, and bladder. Suspect a fracture of the pelvis in any patient who has sustained a high-velocity injury and complains of discomfort in the lower back or abdomen.\nAssess for tenderness.\nInjury to the bladder or the urethra may cause lower abdominal tenderness and evidence of hematuria or blood. FIGURE 32-42 A. To assess for tenderness or instability in the pelvic region, place your hands over the lateral aspect of each iliac crest, and gently compress the pelvis. B. With the patient in a supine position, place your palms over the anterior aspect of each iliac crest, and apply firm but gentle downward pressure. C. Palpate the pubic symphysis with the palm of your hand. A, B, C: \u00a9 Jones & Bartlett Learning.",
        "Dislocation of the Hip": "Dislocates only after significant injury\nMost dislocations are posterior.\nSuspect a dislocation in any patient who has been in an automobile crash and has a contusion, laceration, or obvious fracture in the knee region. Posterior dislocation is frequently complicated by injury to the sciatic nerve.\nDistinctive signs\nSevere pain in the hip\nStrong resistance to movement of the joint\nTenderness on palpation Do not attempt to reduce the dislocated hip in the field.\nSplint the dislocation.\nPlace the patient supine on a backboard.\nSupport the affected limb with pillows.\nSecure the entire limb to the backboard with long straps.\nProvide prompt transport.",
        "Fractures of the Proximal Femur": "Common fractures, especially in older people and patients with osteoporosis\nBreak goes through the neck of the femur, the interochanteric region, or across the proximal shaft of the femur.\nPatients display characteristic deformity.\nLie with the leg externally rotated, and injured limb is usually shorter than the opposite, uninjured limb. Assess the pelvis for any soft-tissue injury and bandage appropriately.\nAssess pulses and motor and sensory functions.\nSplint the lower extremity and transport to the emergency department.",
        "Femoral Shaft Fractures": "Can occur in any part of the shaft, from the hip region to the femoral condyles just above the knee joint\nLarge muscles of the thigh spasm in an attempt to \u201csplint\u201d the unstable limb.\nProduces significant deformity and shortened limb\nThere is often significant blood loss. Bone fragments may penetrate or press on important nerves and vessels.\nCarefully and periodically assess the distal neurovascular function.\nCover any wound with a dry, sterile dressing.\nThese fractures are best stabilized with a traction splint.",
        "Traction Splints": "Used primarily to secure fractures of the femur\nGoals of in-line traction:\nTo stabilize the fracture fragments\nTo align the limb sufficiently\nTo avoid potential neurovascular compromise Do not use for any of these conditions:\nInjuries of the upper extremity\nInjuries close to or involving the knee\nInjuries of the pelvis\nPartial amputations or avulsions with bone separation\nLower leg, foot, or ankle injury",
        "Injuries of Knee Ligaments": "Many different types of injuries occur in this region.\nLigament injuries\nDislocated patella\nBony elements can fracture. With ligament injuries you will generally find:\nSwelling\nOccasional ecchymosis\nPoint tenderness at the injury site\nA joint effusion\nSplint all suspected knee ligament injuries.",
        "Dislocation of the Knee": "These are true emergencies that may threaten the limb.\nLigaments may be damaged or torn.\nDirection of dislocation refers to the position of the tibia with respect to the femur.\nPosterior dislocations\nMedial dislocations Complications may include:\nLimb-threatening popliteal artery disruption\nInjuries to the nerves\nJoint instability\nIf adequate distal pulses are present, splint the knee and transport promptly.",
        "Fractures About the Knee": "May occur at the distal end of the femur, at the proximal end of the tibia, or in the patella\nIf there is an adequate distal pulse and no significant deformity, splint the limb with the knee straight. If there is an adequate pulse and significant deformity, splint the joint in the position of deformity.\nIf the pulse is absent below the level of injury, contact medical control.\nNever use a traction splint.",
        "Dislocation of the Patella Most commonly occurs in teenagers and young adults in athletic activities": "Usually, the dislocated patella displaces to the lateral side and produces significant deformity.\nSplint the knee in the position in which you find it.",
        "Injuries of the Tibia and Fibula Fracture may occur at any place between the knee joint and the ankle joint.": "Often, both bones fracture at the same time.\nStabilize with a padded, rigid long leg splint or an air splint.\nCorrect severe deformity with gentle longitudinal traction.",
        "Ankle Injuries": "The ankle is a commonly injured joint.\nRange from a simple sprains to severe fracture-dislocations\nAny ankle injury that produces pain, swelling, localized tenderness, or the inability to bear weight must be evaluated by a physician. Management\nDress all open wounds.\nAssess distal neurovascular function.\nCorrect any gross deformity by applying traction.\nBefore releasing traction, apply a splint.",
        "Foot Injuries": "Can result in the dislocation or fracture of one or more of the tarsals, metatarsals, or phalanges of the toes\nFrequently, the force of injury is transmitted up the legs to the spine. FIGURE 32-51 After a fall, the force of injury is transmitted up the legs to the spine, sometimes resulting in a fracture of the lumbar spine. \u00a9 Jones & Bartlett Learning. If you suspect a foot dislocation, assess for pulses and motor and sensory functions.\nAssociated with significant swelling but rarely with gross deformity\nTo splint the foot, apply a rigid padded board splint, an air splint, or a pillow splint.\nLeave the toes exposed.",
        "Strains and Sprains General treatment is similar to that of fractures": "RICES\nRest\nIce\nCompression\nElevation\nSplinting",
        "Most often occurs with a fractured tibia or forearm of children": "Typically develops within 6 to 12 hours after injury, as a result of:\nExcessive bleeding\nA severely crushed extremity\nThe rapid return of blood to an ischemic limb Characterized by:\nPain that is out of proportion to the injury\nPain on passive stretching of muscles within the compartment\nPallor\nDecreased sensation\nDecreased power If you suspect the patient has compartment syndrome:\nSplint the affected limb, keeping it at the level of the heart\nTransport immediately.\nReassess neurovascular status frequently during transport."
    },
    {
        "National EMS Education Standard Competencies": "Trauma\nApplies fundamental knowledge to provide basic emergency care and transportation based on assessment findings for an acutely injured patient. Soft Tissue Trauma\nRecognition and management of\nWounds\nBurns\nElectrical\nChemical\nThermal\nChemicals in the eye and on the skin Pathophysiology, assessment, and management\nWounds\nAvulsions\nBite wounds\nLacerations\nPuncture wounds\nIncisions Pathophysiology, assessment, and management (cont\u2019d)\nBurns\nElectrical\nChemical\nThermal\nRadiation\nCrush syndrome",
        "Introduction": "Soft-tissue injuries are common.\nSimple as a cut or scrape\nSerious as a life-threatening internal injury\nDo not become distracted by dramatic open wounds.\nDo not neglect airway obstruction. Soft tissues of the body can be injured through a variety of mechanisms:\nBlunt injury\nPenetrating injury\nBarotrauma\nBurns Soft-tissue trauma is a common form of injury.\nDeath is often related to hemorrhage or infection.\nSoft-tissue injuries can often be prevented by simple protective actions.",
        "The Anatomy and Physiology of the Skin": "The skin is the body\u2019s first line of defense against:\nExternal forces\nInfection\nThe skin is relatively tough, but still susceptible to injury.\nRange from simple bruises and abrasions to serious lacerations and amputations In all instances, the EMT must:\nControl bleeding.\nPrevent further contamination to decrease the risk of infection.\nProtect wounds from further damage.\nApply dressings and bandages to various parts of the patient\u2019s body. Skin varies in thickness.\nThinner in the very young and very old\nThinner on the eyelids, lips, and ears than on the scalp, back, and soles of feet The skin has two principal layers\u2014epidermis and the dermis.\nEpidermis: tough, external layer\nDermis: inner layer FIGURE 27-1 The skin comprises a tough external layer called the epidermis and a vascular inner layer called the dermis. \u00a9 Jones & Bartlett Learning Skin covers all the external surfaces of the body.\nBodily openings are lined with mucous membranes.\nProvide a barrier against bacterial invasion Skin serves many functions.\nBarrier against infection\nSensory organ\nHelps body regulate temperature\nHelps maintain fluid balance Any break in the skin may allow bacteria to enter and increases the possibilities of:\nInfection\nFluid loss\nLoss of temperature control Three types of soft-tissue injuries:\nClosed injuries\nOpen injuries\nBurns",
        "Pathophysiology of Closed and Open Injuries Pathophysiology": "Cessation of bleeding is the primary concern.\nThe next wound healing stage is inflammation.\nA new layer of cells is then moved into the damaged area.\nNew blood vessels form.\nCollagen provides stability to the damaged tissue and joins wound borders.",
        "A contusion causes bleeding beneath the skin but does not break the skin.": "A hematoma is blood collected within damaged tissue or in a body cavity.\nA crushing injury occurs when a significant amount of force is applied to the body. When an area of the body is trapped for longer than 4 hours, crush syndrome can develop.\nWhen the tissues are crushed beyond repair, muscle cells die and release harmful substances into the surrounding tissues. Compartment syndrome results from the swelling that occurs whenever tissues are injured.\nSevere closed injuries can also damage internal organs.\nAssess all patients with closed injuries for more serious hidden injuries.",
        "Open Injuries": "Four types:\nAbrasions\nLacerations\nAvulsions\nPenetrating wounds An abrasion is a wound of the superficial layer of the skin.\nCaused by friction when a body part rubs or scrapes across a rough or hard surface FIGURE 27-5 Abrasions usually do not penetrate\ncompletely (A) through the dermis, but blood may ooze from the capillaries (B). These wounds are typically superficial and result from rubbing or scraping across a hard, rough surface. A: \u00a9 American Academy of Orthopaedic Surgeons. B: \u00a9 Jones & Bartlett Learning. A laceration is a jagged cut. \nAn incision is a sharp, smooth cut. FIGURE 27-6 Lacerations vary in depth (A) and can\nextend through the skin and subcutaneous tissue to the\nunderlying muscles, nerves, and blood vessels (B). These\nwounds can be smooth or jagged, depending on the object that caused the injury. A: \u00a9 AUYNantapon/Shutterstock; B: \u00a9 Jones & Bartlett Learning. An avulsion separates various layers of soft tissue so that they become either completely detached or hang as a flap. FIGURE 27-7 Avulsions are injuries characterized by\ncomplete separation of tissue (A) or tissue hanging as a\nflap (B). Significant bleeding is common. A, B: \u00a9 Jones & Bartlett Learning. An amputation is an injury in which part of the body is completely severed.\nA penetrating wound is an injury resulting from a piercing object. Stabbings and shootings often result in multiple penetrating injuries.\nAssess the patient carefully to identify all wounds.\nCount the number of penetrating injuries.\nDetermine the type of gun when possible. Blast injuries\nPrimary blast injury: damage caused by the blast wave and sudden pressure changes\nSecondary blast injury: damage results from flying debris\nTertiary blast injury: victim is thrown by explosion, perhaps into an object",
        "Patient Assessment of Closed and Open Injuries More difficult to assess a closed injury than an open injury": "You can see an open injury.\nConsider the possibility of a closed injury when you observe:\nBruising\nSwelling\nDeformity\nThe patient reporting pain",
        "Scene Size-up Scene safety": "Mechanism of injury\nLook for indicators of the MOI as you assess the scene.\nThe MOI may provide information about potential safety threats.\nEvaluate scene safety and consider additional resources. Scene safety\nObserve the scene for hazards and safety threats.\nEnsure that the factors that led to the patient\u2019s burn injury do not pose a hazard.\nMechanism of injury\nDetermine the type of burn that has been sustained and the MOI. Mechanism of injury (cont\u2019d)\nGather information from the patient about the extent of the injury.\nAssess the scene for environmental hazards.\nDetermine the number of patients.\nCall for additional resources early. \nConsider the potential for other injuries.",
        "Primary Assessment": "Identify life threats and transport priority.\nForm a general impression.\nLook for indicators of the patient\u2019s condition.\nCheck for more serious hidden injuries.\nCheck for responsiveness. Circulation\nSignificant bleeding is an immediate life threat and must be controlled before the airway is open.\nIf the patient has obvious life-threatening external bleeding:\nControl the bleeding\nManage the airway\nAssess and treat for shock Airway and breathing\nEnsure that the patient has a clear and patent airway.\nProtect the patient from further spinal injury.\nAssess the patient for adequate breathing.\nProvide high-flow oxygen or assist ventilations if needed.\nInspect and palpate the chest for DCAP-BTLS. Transport decision\nImmediately transport in these cases:\nPoor initial general impression\nAltered level of consciousness\nDyspnea\nAbnormal vital signs\nShock\nSevere pain Begin with a rapid exam.\nForm a general impression.\nLook for clues to determine the severity of injuries and the need for rapid treatment.\nBe suspicious of clues that may indicate abuse.\nConsider the need for manual spinal stabilization.\nCheck for responsiveness using the AVPU scale. Airway and breathing\nEnsure that the patient has a clear and patent airway.\nBe alert to signs that the patient has inhaled hot gases or vapors:\nSinged facial hair\nSoot present in and around the airway Airway and breathing (cont\u2019d)\nHeavy amounts of secretions and frequent coughing may indicate a respiratory burn.\nQuickly assess for adequate breathing.\nInspect and palpate the chest wall for DCAP-BTLS. Circulation\nAssess the pulse rate and quality.\nDetermine perfusion based on the patient\u2019s skin condition, color, temperature, and capillary refill time.\nControl significant bleeding.\nAssess for shock. Transport decision\nConsider rapid transport for a patient who has:\nAn airway or breathing problem\nSignificant burn injuries\nSignificant external bleeding\nSigns and symptoms of internal bleeding\nConsider consulting ALS providers.",
        "History Taking Investigate the chief complaint.": "Use SAMPLE, OPQRST, and DCAP-BTLS for a well-rounded assessment.\nIf the patient is not responsive, attempt to obtain the history from another source.\nChronic medical conditions may complicate soft-tissue injuries. Investigate the chief complaint.\nBe alert for signs and symptoms of other injuries due to the MOI.\nTypical signs of a burn:\nPain\nRedness\nSwelling\nBlisters\nCharring SAMPLE history\nAlong with the SAMPLE history, ask the following questions:\nAre you having any difficulty breathing?\nAre you having any difficulty swallowing?\nAre you having any pain?\nCheck whether the patient has an emergency medical identification device.",
        "Secondary Assessment": "Includes assessing interventions and repeating vital signs\nTypically performed en route to the ED\nAssess all anatomic regions Physical examination\nListen to breath sounds.\nDetermine the respiratory rate.\nNote the pattern and quality of respiratory effort.\nAssess for asymmetric chest wall movement. Physical examination (cont\u2019d)\nAssess the neurologic system.\nAssess the musculoskeletal system with a detailed exam of entire body.\nAssess all anatomic regions. Vital signs\nReassess the vital signs to identify how quickly the patient\u2019s condition is changing.\nSigns that indicate hypoperfusion and the need for rapid transport:\nTachycardia\nTachypnea\nLow blood pressure\nWeak pulse\nCool, moist, and pale skin Physical examination\nPerform an exam of the entire body.\nAssess the patient from head to toe looking for DCAP-BTLS.\nMake a rough estimate, using the rule of nines, of the extent of the burned area.\nDetermine the classification of the burn.\nDetermine the severity of the burn.\nPackage the patient for transport. Physical examination (cont\u2019d)\nDetermining an early set of vital signs will help you to know how the patient is tolerating his or her injuries.\nOxygen saturation monitor\nCarbon monoxide monitor",
        "Reassessment": "Repeat the primary assessment.\nAssess the effectiveness of prior treatments.\nReassess vital signs and the chief complaint. Recheck patient interventions.\nReassess bandaging.\nIdentify and treat changes in the patient\u2019s condition. Communication and documentation\nDescription of the MOI\nPosition in which you found the patient\nAmount of blood loss\nLocation and description of any soft-tissue injuries or other wounds\nSize and depth of the injury\nHow you treated the injuries Repeat the primary assessment and reassess the patient\u2019s vital signs.\nReassess the chief complaint.\nReevaluate interventions.\nStop the burning process.\nAssess and treat breathing.\nSupport circulation. Reassess interventions (cont\u2019d)\nProvide rapid transport.\nOxygen is mandatory for inhalation burns and large body surface area burns.\nIf the patient has signs of hypoperfusion, treat aggressively for shock and provide rapid transport. Communication and documentation\nProvide hospital personnel with a description of how the burn occurred.\nDescribe the extent of the burns:\nAmount of body surface area involved\nDepth of the burn\nLocation of the burn\nDocument if special areas are involved.",
        "Emergency Medical Care for Closed Injuries": "No special emergency care for small contusions\nExtensive injuries could lead to hypovolemic shock.\nClosely watch any area of injury, no matter how minor. Treat closed soft-tissue injury using the RICES mnemonic:\nRest\nIce\nCompression\nElevation\nSplinting Signs of developing shock\nAnxiety or agitation\nChanges in mental status\nIncreased heart rate\nIncreased respiratory rate\nDiaphoresis\nCool or clammy skin\nDecreased blood pressure",
        "Emergency Medical Care for Open Injuries": "Before caring for the patient, follow standard precautions.\nIf life-threatening bleeding is observed, assign a team member to apply direct pressure.\nCover wounds of the chest, upper abdomen, or upper back with an occlusive dressing. Control bleeding using:\nDirect, even pressure and elevation\nPressure dressings and/or splints\nTourniquets All open wounds are assumed to be contaminated and present a risk of infection.\nControl bleeding by splinting the extremity, even if there is no fracture. Abdominal wounds\nAn open wound in the abdominal cavity may expose internal organs.\nIn an evisceration, the organs protrude through the wound. FIGURE 27-12 An abdominal evisceration is an open wound to the abdomen in which organs protrude through the wound. \u00a9 Dr. M. A. Ansary/Photo Researchers, Inc. Abdominal wounds (cont\u2019d)\nCover the wound with sterile gauze.\nSecure the gauze with an occlusive dressing.\nKeep the organs moist and warm. FIGURE 27-13 A. Cover exposed organs with sterile gauze compresses moistened with sterile saline solution. B. Place an occlusive dressing over the compresses and secure it in place by taping all four sides. \u00a9 Jones & Bartlett Learning. Impaled objects\nRemove an impaled object only when:\nThe object is in the cheek or mouth and obstructs the airway.\nThe object is in the chest and interferes with CPR. Neck injuries\nOpen neck injuries can be life threatening.\nOpen veins may suck in air and cause cardiac arrest.\nCover the wound with an occlusive dressing.\nApply manual pressure but do not compress both carotid arteries at the same time. Small-animal bites\nA small animal\u2019s mouth is heavily contaminated with virulent bacteria.\nWounds may require:\nDebridement\nAntibiotics\nTetanus prophylaxis\nSurgical repair\nBites should be evaluated by a physician. A major concern is the spread of rabies.\nAcute, potentially fatal viral infection of the central nervous system\nCan affect all warm-blooded animals\nTransmitted through biting or licking an open wound\nPrevented only by a series of special vaccine injections Human bites\nThe human mouth contains an exceptionally wide range of bacteria and viruses.\nRegard any human bite that has penetrated the skin as a very serious injury.\nCan result in a serious, spreading infection Emergency treatment\nApply a dry, sterile dressing.\nPromptly immobilize the area with a splint or bandage.\nProvide transport to the ED. FIGURE 27-17 Human bites can result in a serious,\nspreading infection. Thus, patients must be evaluated at the hospital. \u00a9 American Academy of Orthopaedic Surgeons.",
        "Burns": "Among the most serious and painful of all injuries\nA burn occurs when the body receives more radiant energy than it can absorb.\nSources of this energy may include heat, toxic chemicals, and electricity. Always perform a complete assessment to determine whether other serious injuries are present.\nChildren, older patients, and patients with chronic illnesses are more likely to experience shock from burn injuries.",
        "Pathophysiology of Burns": "Pathophysiology \nBurns are soft-tissue injuries that are created by the transfer of radiation, thermal, or electrical energy.\nThermal burns occur when the skin is exposed to temperatures higher than 111\u00baF. Pathophysiology (cont\u2019d)\nSeverity of a thermal injury correlates directly with:\nTemperature\nConcentration\nAmount of heat energy possessed by the object or substance\nDuration of exposure Pathophysiology (cont\u2019d)\nThe greater the heat energy, the deeper the wound.\nPeople reflexively limit heat energy and exposure time.\nThey cannot do so if unconscious or trapped.",
        "Complications of Burns": "When a person is burned, the skin that acts as a barrier is destroyed.\nBurns create a high risk for:\nInfection\nHypothermia\nHypovolemia\nShock Burns to the airway are of significant importance.\nCircumferential burns of the chest can compromise breathing.\nCircumferential burns of an extremity can lead to neurovascular compromise and irreversible damage.",
        "Burn severity depends on:": "Depth of burn\nExtent of burn\nCritical areas involved\nFace, upper airway, hands, feet, genitalia\nPreexisting medical conditions or other injuries\nPatient younger than 5 or older than 55 years Depth of burns\nSuperficial (first-degree) burns\nInvolve only the top layer of skin\nPartial-thickness (second-degree) burns\nInvolve the epidermis and some portion of the dermis\nBlisters are present.\nFull-thickness (third-degree) burns\nExtend through all skin layers FIGURE 27-18 Classification of burns. A. Superficial (first-degree) burns involve only the  pidermis. The skin turns red but does not blister or actually burn through. B. Partial-thickness (second-degree) burns involve some of the dermis, but they do not destroy the entire thickness of the skin. The skin is mottled, white to red, and is often blistered. C. Full-thickness (third-degree) burns extend through all layers of the skin and may involve subcutaneous tissue and muscle. The skin is dry, leathery, and often either white or charred. A: \u00a9 Amy Walters/Shutterstock; B: \u00a9 American Academy of Orthopaedic Surgeons; C: \u00a9 E.M. Singletary, MD. Used with permission; (Illustration) \u00a9 Jones & Bartlett Learning. Extent of burns\nEstimated using the rule of palm or rule of nines\nThe proportions differ for infants, children, and adults.\nInclude only partial-thickness and full-thickness in estimations of the extent of burn injury. FIGURE 27-19 The rule of nines is a quick way to estimate the amount of surface area that has been burned; it divides the body into sections, each representing approximately 9% of the total body surface area. The proportions differ for infants, children, and adults. \u00a9 Jones & Bartlett Learning.",
        "Patient Assessment of Burns When you are assessing a burn, it is important to classify the victim\u2019s burns.": "Classification of burns is based on:\nSource of the burn\nDepth of the burn\nSeverity of the burn",
        "Emergency Medical Care for Burns Stop the burning process.": "Prevent additional injury.",
        "Thermal Burns": "Caused by heat\nMost commonly caused by scalds or an open flame\nComing in contact with hot objects produces a contact burn. A steam burn can produce a topical (scald) burn.\nA flash burn is produced by an explosion.\nMay briefly expose a person to very intense heat\nLightning strikes can cause a flash burn. Management\nStop the burning source, cool the burned area, and remove all jewelry.\nIncreased exposure time will increase damage to the patient.\nAll patients should have a dry dressing applied to:\nMaintain body temperature\nPrevent infection\nProvide comfort",
        "Inhalation Burns": "Can occur when burning takes place in enclosed spaces without ventilation\nUpper airway damage is often associated with the inhalation of superheated gases.\nLower airway damage is often associated with the inhalation of chemicals and particulate matter. You may encounter severe upper airway swelling, which requires immediate intervention.\nConsider requesting ALS backup.\nThe combustion process produces a variety of toxic gases. Carbon monoxide intoxication should be considered whenever a group of people in the same place all report a headache or nausea.\nManagement\nFirst ensure your own safety and the safety of your coworkers. Management (cont\u2019d)\nPrehospital treatment of a patient with suspected hydrogen cyanide poisoning includes decontamination and supportive care.\nCare for any toxic gas exposure includes:\nRecognition\nIdentification\nSupportive treatment",
        "Chemical Burns": "Can occur whenever a toxic substance contacts the body\nGenerally caused by strong acids or strong alkalis\nThe eyes are particularly vulnerable. Severity of the burn is directly related to three factors:\nType of chemical\nConcentration of the chemical\nDuration of the exposure\nWear appropriate chemical-resistant gloves and eye protection. Management\nRemove any chemical from the patient.\nAlways brush dry chemicals off the skin and clothing before flushing with water.\nRemove the patient\u2019s clothing. FIGURE 27-21 Brush off dry chemicals before you flush the burned area with water. \u00a9 Jones & Bartlett Learning. Management (cont\u2019d)\nFor liquid chemicals, immediately begin to flush the burned area with lots of water.\nContinue flooding the area for 15 to 20 minutes after the patient says the burning pain has stopped.\nIf the patient\u2019s eye has been burned, hold the eyelid open while flooding the eye.\nConduct proper decontamination prior to loading the patient.",
        "May be the result of contact with high- or low-voltage electricity": "For electricity to flow, there must be a complete circuit between the source and the ground.\nInsulator: any substance that prevents this circuit \nConductor: any substance that allows a current to flow The human body is a good conductor.\nThe type of electric current, magnitude of current, and voltage have effects on the seriousness of the burn.\nYour safety is of particular importance.\nNever attempt to remove someone from an electrical source unless you are specially trained to do so. A burn injury appears where the electricity enters and exits the body.\nTwo dangers:\nThere may be a large amount of deep tissue injury.\nThe patient may go into cardiac or respiratory arrest from the electric shock. FIGURE 27-25 Electrical burns, like gunshot wounds, have entrance and exit wounds.  The exit wound can be extensive and deep. \u00a9 Chuck Stewart, MD. Management\nIf indicated, begin CPR on the patient and apply an AED.\nBe prepared to defibrillate if necessary.\nGive supplemental oxygen and monitor the patient closely.\nTreat soft-tissue injuries with dry, sterile dressings.\nProvide prompt transport.",
        "Taser Injuries In recent years, law enforcement has increased its use of Tasers.": "Potential complications for patients with underlying disorders.\nUse of a Taser has been associated with dysrhythmias and sudden cardiac arrest.\nMake sure you have access to an AED when responding to patients who have been exposed to Taser shots.",
        "Radiation Burns": "Potential threats include:\nIncidents related to the use and transportation of radioactive isotopes\nIntentionally released radioactivity in terrorist attacks\nFirst determine if there has been a radiation exposure and then whether ongoing exposure continues to exist. Three types of ionizing radiation:\nAlpha\nLittle penetrating energy easily stopped by the skin\nBeta\nGreater penetrating power, but blocked by simple protective clothing\nGamma\nVery penetrating; easily passes through the body and solid materials Most ionizing radiation accidents involve gamma radiation (x-rays).\nManagement\nMaintain a safe distance and wait for the hazmat team to decontaminate the patient.\nCall for additional resources to remove the patient\u2019s clothes.\nBegin XABCs and treat burns or trauma.\nIrrigate open wounds. Management (cont\u2019d)\nNotify the emergency department.\nIdentify the radioactive source and the length of the patient\u2019s exposure to it.\nLimit your duration of exposure.\nIncrease your distance from the source.\nAttempt to place shielding between yourself and the sources of gamma radiation.",
        "Dressing and Bandaging": "All wounds require bandaging.\nSplints can help control bleeding and provide firm support for dressing.\nThere are many different types of dressings and bandages. FIGURE 27-27 A. Many types of sterile dressings are used for covering open wounds, including universal dressings, gauze pads, adhesive dressings, and occlusive dressings. B. Bandages keep dressings in place and include soft roller bandages, triangular bandages, and adhesive tape. Splints may also be used to hold dressings in place. A: \u00a9 MedstockPhotos/Shutterstock; B: \u00a9 thodonal88/Shutterstock. Dressings and bandages have three functions:\nTo control bleeding\nTo protect the wound from further damage\nTo prevent further contamination and infection",
        "Sterile Dressings": "Most wounds will be covered by:\nUniversal dressings\nConventional 4 \uf0b4 4-inch and 4 \uf0b4 8-inch gauze pads\nAssorted small adhesive-type dressings and soft self-adherent roller dressings\nUniversal dressings are ideal for covering large open wounds. Gauze pads are appropriate for smaller wounds.\nAdhesive-type dressings are useful for minor wounds.\nOcclusive dressings prevent air and liquids from entering (or exiting) the wound.",
        "To keep dressings in place during transport, you can use:": "Soft roller bandages\nRolls of gauze\nTriangular bandages\nAdhesive tape\nSelf-adherent, soft roller bandages are easiest to use. Adhesive tape holds small dressings in place and helps to secure larger dressings.\nDo not use elastic bandages to secure dressings.\nThe bandage may become a tourniquet and cause further damage. Splints are useful in stabilizing broken extremities.\nCan be used with dressings to help control bleeding from soft-tissue injuries\nIf a wound continues to bleed despite the use of direct pressure, quickly proceed to the use of a tourniquet."
    },
    {
        "epidermis": "outermost layer of the skin. dead and dying cells make up this layer and are regularly lost and replaced. provides protection against pathogens and bacteria.",
        "dermis": "layer below the epidermis containing nerve receptors, blood vessels and glands. important in temperature control.",
        "subcutaneous tissue": "composed of fat and connective tissues. this layer helps with insulation.",
        "functions of skin": "1) protection from infection. 2) organ of sensation i.e. pain, temperature, pressure. 3) prevent internal fluid loss and external fluid infiltration. 4) temperature regulation. 5) insulation from trauma. 6) uv protection and vitamin d production.",
        "thermal burns": "this burn occurs when exposed to high molecular movement or heat. high heat/high exposure times lead to chemical and physical changes that can cause cell death and progressive injury.",
        "factors affecting thermal burns": "1) the time of exposure. 2) the heat of exposure. 3) the area of exposure.",
        "electrical burns": "this involves the exposure to electricity which travels through the body from an area of high electron to an area of low electron. an entrance and exit wound occur externally and internal damage can be expected through the area between those points.",
        "other than thermal injury, what other complications can occur due to electrical exposure?": "1) nervous tissue injury. 2) vascular injury. 3) muscular convulsion/contraction. 4)respiratory muscle immobilized- apnea. 5) disruption of cardiac electrical cycle - cardiac arrest. 6) other thermal burns may occur due to ignition of clothing or arcing electricity.",
        "what influences greater damage and injury with electrical exposure?": "1) amperage (more important than voltage). 2) ac current more lethal than dc current. 3) voltage. 4) length of exposure. 5) conductivity of tissue exposed. 5) distance between entrance and exit point.  6) small area of contact = greater concentration = greater damage.",
        "amperage": "this is the rate of flow or current. even at relatively low amps, significant injury can occur.",
        "voltage": "this is the difference between the area of high electron to the area of low electrons. this can be thought of as a \"pressure\". significant injury may or may not occur at relatively high voltage exposure, but this depends on other factors and exposure is by no means safe.",
        "alternating current (ac)": "this is a current that alternates its direction and magnitude. it is commonly found in households and business and is used in transmission lines. exposure to this frequency can cause muscular convulsion that cause the victim to grab the source and prolong the exposure.",
        "direct current (dc)": "this is a current flows in one direction. it is commonly found in batteries and solar power units. exposure to this type of current is less likely to cause severe injury compared to ac."
    },
    {
        "introduction": "burn injuries can originate from many different sources. each causing different presentations. causing changes inside the body, affecting areas dependent on source and severity. children less than 5 years of age and elderly are at high risk of death due to burns. age, previous medication conditions, protective gear, and skin thickness can affect the severity of the burn injuries. in some cases, the complete determination of the source, exposure amount, forces exerted on the body, and length of exposure can be difficult to determine. airway compromise, hypoxia, and breathing complications can happen, with increased risk for individuals trapped in small spaces in the presence of increased toxic concentration. in the presence of scalding and contact burns from objects in children, older people, and people with disability may be signs of abuse. unusual history patterns, shaped burns, unusual patterns to the genitalia, thighs, and buttocks are often time seen in abuse cases.",
        "anatomy and physiology of the skin": "burn injuries to the skin are commonly seen in mild to severe burns. the skin helps to maintain homeostasis of the body. helping to regulate temperature, prevent loss of water from the body, and provides sensory input. the skin also provides protection to exposures from temperature, ultraviolet radiation, mechanical forces, toxic chemicals, and invading microorganisms.",
        "layers of the skin": "epidermis is the outermost layer of skin. this layer defends against water, dust microorganisms, and mechanical stress. the outer most layer of skin contains dead skin cells that are shed followed by three inner layer of living cells that constantly divide to give new cells to be shed off. also containing melanin granules that provide protection that varies on the concentration. dermis is a tough and highly elastic beneath the epidermis. consisting of connective tissues, collagen fibers, elastin fibers, and a mucopolysaccharide gel. here we can find our nerve endings, cutaneous blood vessels, sweat glands, hair follicles, and sebaceous gland. subcutaneous layer is beneath the dermis. this layer mainly contains adipose tissue that provides insulation and as a containment for energy reserve.",
        "types of burns": "thermal burns occurs when the skin has been exposed to temperatures higher than 111 or when the heat absorbed into the body exceeds the tissues capacity to dissipate it. the temperature, concentration, or amount of heat energy, and duration of exposure plays an important part in the severity. the greater the heat energy, the deeper the wound. flame burns often causes a deep burn and may cause inhalation injures. scald burns from hot liquids are most commonly seen in children and handicapped adults. they can also happen to anyone, with higher incidence while cooking. these burns often times can cover a large surface area. the hot liquids can be absorbed into the individuals clothing and continue to cause burns. oils and grease can adhere to the skin causing deep burns. contact burns occur when coming into contact with a hot object. usually does not cause deep injuries due to self preservation reflexes. steam burns can cause a topical scald burn. minor burns are common when microwaving food covered with plastic wrap. these types of burns are notorious for causing airway burns and injury. flash burns are a rare type of thermal burns. usually caused by an exposure to very intense heat sources. these injuries are usually minor but it depends on the source.",
        "chemical burns to the skin": "dependent on the nature of the chemical involved, the concentration/quality, the chemical state or temperature of the chemical, exposure time frame, and the depth that the chemical penetrates. acids can cause pain and coagulation necrosis and the underlying deep tissues are typically not affected. bases and alkalis can cause a little bit of pain, liquefaction necrosis may occur. oxidizing agents create tissue damage by releasing heat. these agents can also cause systemic poisoning. phosphorus can cause burns when exposed to air, while also potentially cause a systemic poisoning. vesicants can cause blistering of the skin. in the case of inhalation it can lead to respiratory compromise.",
        "inhalation burns and intoxication": "rapid and serious airway compromise may occur. heat and toxic chemicals can can irritation. typically one may present with coughing, wheezing, and edema of the upper airway causing stridor. steam and hot particulate mater can cause lower airway damage and irritation. upper airway injuries are mostly contributed to the inhalation of superheated gases. smoke inhalation: may cause thermal burns, hypoxia, tissue damage, and toxic systemic affects. caused by chemicals in the smoke. carbon monoxide poisoning: causes displacement of oxygen from the alveolar air and hemoglobin. carbon monoxide (co) binds to hemoglobin at least 250 times easier than oxygen. a blood level of co is about 2% in most people. for heavy smokers they may have 4-8% of co in their blood. if an individuals blood level of co reaches 50% or higher it may cause mortality. it is typical to see patients with spo2 saturations that are normal or better. there are spo2 sensors that can read the level of co in the blood.",
        "signs of airway burns/injury": "hoarseness cough signed nasal or facial hair facial burns carbon in the sputum history of burn in an enclosed space laryngeal edema can develop quickly.",
        "inhalation chemical burns": "water solubility of a chemical correlates to the variety of signs, symptoms, and affects inside the body. highly water soluble substances can react with the mucous membranes. leading to immediate irritation and swelling. moderately water soluble substances can react with the mucous membranes over time. how quickly and severe of the reaction is dependent on concentration inhaled. slightly water soluble substances can cause inflammation and pulmonary edema at the alveolar level hours or days after exposure. this is due to the substances ability to penetrate deeper into the respiratory tract. it is important to be on the look out for airway compromise.",
        "electrical burns and injuries": "typically will cause significant internal injuries with minimal obvious evidence. the severity of tissue injury is related to the resistance of the bodies tissues, current intensity, and exposure time. external injuries will show an entrance and exit wound that may be difficult to locate, but need to be found. the entrance wound my be small in size, while the exit will typically be extensive and deep. when the electrical current is inside the body it will usually travel along the blood vessels, nerves, and muscles. leading to extensive damage to the tissues in its pathway. electrical burns causes three types of burns a true electrical injury is the most common type of electrical burn. here the current is under high concentration at the entrance and exit site. giving the entrance and exit sites the characteristic bulls-eye lesions. with a centralized charred zone of full-thickness burns; a middle zone of cold, gray, dry tissue; and an outer red zone of coagulation necrosis. a arc-type of flash burn is caused by an arcing of electrical current. typically the arc has a temperature between 3,000-20,000 creating charring. a flame burn happens when the electricity ignites a persons clothing or surroundings. classified as serious burns due to the high potential of serious internal injury caused as the current travels through the body. can interrupt the hearts electrical activity leading to cardiac arrest. death in electrical burn patients is usually due to asphyxia and cardiac arrest. neurological affects seen can include peripheral nerve damage, muscle spasms, seizures, delirium, confusion, coma, and temporary quadriplegia.",
        "lightning strikes": "these electrical events are rare, but can occur. extremely high energy level that is direct. exposure time in just milliseconds can lead to injuries that rival blast injuries. can cause a complete depolarization of the hearts cells. may lead to respiratory arrest. if cardiac function is not stopped or returns quickly there is still a risk that respiratory arrest may occur if not managed timely. prevention is the most effective way to prevent injury. educating the public what to do in the event of a lightning storm includes not standing out as the tallest object that is a good conductor, avoiding standing under or near the tallest object that is a good conductor, avoid being in contact with good conductors, and taking shelter in a substantial structure that provide protection from a lightning strike.",
        "radiation burns": "are rare but can be seen in industrial sites, during the transportation of radioactive isotopes, medical care facilities that use radioactive materials, and potential acts of violence. alpha radiation can be stopped by the skin. beta radiation can penetrate down through the skin, but can be blocked by simple protective clothing that is designed for this purpose. gamma radiation can perpetrate and easily pass through the body and solid materials. the amount of exposure and time of exposure affects the severity and affects observed. scene safety and size up are paramount in the event of a radioactive substance is involved. ensure you are wearing the the appropriate level of protective gear that may be available through the hazardous materials response team. knowing what resources, operating guidelines, and hospital designation to take these types of patients to is vital prior to this type of event occurring. acute radiation syndrome: causes hematologic, central nervous system, and gastrointestinal changes over a period of time that may not be witnessed by initial ems interaction. if the patient has been rendered unresponsive by radiation or vomited within 10 minutes of exposure will not survive. vomiting in less than an hour after exposure are considered to have experienced a severe exposure. these individuals have a 30-80% change of survival. vomiting within 1-2 hours after exposure means that these patients have 95-100% of survival. radiation contact burns: can cause a local soft-tissue injury. resembling a superficial sunburn to a chemical burn. typically these injuries will appear within hours to days of the exposure.",
        "identification of burns": "cellular change zones zone of coagulation: this is the central area of skin that has suffered the most damage. there is little or no blood flow to the injured tissues within this zone. zone of stasis: surrounds the zone of coagulation. this area has decreased blood flow along with inflammation. necrosis may occur within 24-48 hours after injury. increased likelihood with burn shock. zone of hyperemia: the area that is least affected by the thermal injury. these cells will typically recover in 7-10 days.",
        "burn classifications": "1st degree burns (superficial burns): affects the epidermis only. presents as redness with swollen. blistering is typically not noted. with palpation the color will change to blanched and then return. can cause varying degree of pain due to the nerve endings being damaged or becoming exposed. will typically heal spontaneously in 3-7 days. 2nd degree burns (partial-thickness burns): involves the epidermis and varying degrees of the dermis. the deeper the partial-thickness burns are more painful. the sensation of the deep physical pressure is still intact. contains two additional categories. moderate partial-thickness burns display with redness of the skin. palpation results in blanching that returns to the red coloration. blisters and cellular leakage is present. individual may experience pain. the hair follicles remain intact. these burns heal spontaneously but scarring is common. deep partial-thickness burns can extend into the dermis causing damage to the follicles, sweat glands, and sebaceous glands. commonly occurs due to hot liquids, seam, or grease. can be difficult to differentiate from a full-thickness burn. 3rd degree burns (full-thickness burns): creates destruction of both the epidermis and dermis into the subcutaneous membrane. with these burns the skins ability to regenerate is no longer capable. the skin may have a white and waxy, brown and leathery (also known as eschar), or charred appearance. there is no capillary refill. capillaries have been destroyed. nerves have sustain varying degree of damage. individual may not have sensory input, meaning that pain is not present. there is usually significant pain in the surrounding areas of the 3rd degree burn.",
        "circumferential burns": "these burns can wrap around the neck, chest, abdomen, and extremities. progressive edema is common, even in some cases the edema can act as a tourniquet. these burns to the neck and chest can cause airway obstruct along with restricting respiratory compliance. in the extremities obstructed blood flow can occur. individuals with these types of burns need to be transported quickly for definitive treatment.",
        "classification of burns in adults": "critical (severe) burns: full-thickness burns involving hands, feet, face, upper airway, or genitalia. circumferential burns of other areas. full-thickness burns covering more than 10% of the total body surface area (tbsa). partial-thickness burns covering more than 30% of the tbsa. burns associated with respiratory injury (smoke inhalation or inhalation injury) burns complicated by fractures burns on patients younger than 5 years or older than 55 years that would be classified as moderate in young adults. moderate burns: full-thickness burns involving 2-10% of the tbsa (excluding hands, feet, face, genitalia, and upper airway). partial-thickness burns covering 15-30% of the tbsa. superficial burns covering more than 50% of the tbsa. minor burns: full-thickness burns covering less than 2% of the tbsa. partial-thickness burns covering less than 15% of the tbsa. superficial burns covering less than 50% of the tbsa.",
        "classification of burns in infants and children": "critical (severe) burns: any full-thickness burns. partial-thickness burns covering more than 20% of the tbsa. moderate burns: partial-thickness burns covering 10-20% of the tbsa. minor burns: partial-thickness burns covering less than 10% of the tbsa.",
        "burn shock": "sets in in 6-8 hour period and is typically seen while the patient is in the hospital setting. if a patient is in shock in the field it is recommended to look for other injuries as the source of the shock. is managed in definitive care.",
        "calculating burns for total body surface area (tbsa)": "rule of nines infants head: 18% arms: 9% front of core: 18% back of core: 18% genitalia: 1% legs: 13.5% child head: 12% arms: 9% front of core: 18% back of core: 18% genitals: 1% legs: 16.5% adult head: 9% arms: 9% front of core: 18% back of core: 18% genitals: 1% legs: 18% rules of palms (ones) method of using one of the patients palms and fingers to represent 1% of the tbsa. used on patients with less than 10% of the body burned or if the burn is unusual in shape.",
        "prehospital treatments critical to burn patients": "safety of yourself, crew, and others is paramount! do not delay scene time with burn patients. airway management airway management categories. 1. the patient with an acutely deteriorating airway who requires immediate intubation. 2. the patient with a deteriorating airway from burns and inhalation injuries who might require intubation. 3. the patient with an airway that is currently patent, but who has a history consistent with risk factors for eventual airway compromise. cooled humidified oxygen via a high-output nebulizer can help with these patients. 4. the patient who has no signs of or risk factors of airway compromise, who is in no distress. limiting the aggressive administration of oxygen while providing supplemental oxygen may be beneficial to patients, even when not in distress.",
        "fluid resuscitation": "patients with more than 20% bsa burns will need fluid resuscitation. for the next 24-48 hours after the burn occurs, the patient needs to receive fluid resuscitation to prevent burn shock from occurring. in the first 6-8 hours post burn the patient will become hypovolemic due to fluid shifting. is not be be completed in the prehospital setting, but should be considered. iv access should be placed as soon as possible, however, access should not delay proper patient care and transport. avoid placement in burned tissue if able to. consensus formula (parkland formunla) used to calculate how much fluids the patent should receive in 24 hours after the burn event. equation: 24 hours= 4ml x weight x %tbsa burned. now the first half of your total volume to be infused will be given in the first 8 hours. the second half will be given in the following 16 hours.",
        "pain management": "you should consider aggressive pain management. these patients may require a higher doses of pain medications than usual. partially due to the patient having metabolism rates that have being accelerated. morphine and fentanyl are still the medications of choice.",
        "burn center criteria": "partial-thickness burns of more than 10% of the tbsa. burns involve the face, hands, feet, genitalia, perineum, or major joints. full-thickness burns in any age group electrical burns chemical burns inhalation burns burns with complex preexisting medical conditions that could complicate management, prolong recovery, or affect mortality. burns and concomitant trauma in which the burn injury poses the greatest risk of morbidity or mortality. burn injury that requires special social, emotional, or long-term rehabilitation.",
        "specific burn treatments": "thermal burns cover burns that are less than 10% tbsa with a moist dressing. cover burns that are above 10% tbsa with a dry dressing. patients with large surface area burns are likely to develop hypovolemia and hypothermia. superficial burns within the first hour of the burn, immersion of the burned area in cool water or application of a cold compresses is recommended. burned hands or feet may be soaked directly in cool water or a cold compress may be applied. burns to the face can have towels soaked in cold water applied. never apply salves, ointments, creams, sprays, or ice to superficial burns because this can cause worsening tissue injury.",
        "partial-thickness burns": "if cooling of the burned area occurs within the first hour it can diminish edema and provide significant pain relief. elevation of burned extremities to help minimize edema. do not rupture blisters. pain management and fluid resuscitation.",
        "full-thickness burns": "even though patients may not have pain, the patient can still be in discomfort. cover burns with a dry sterile dressing. begin fluid resuscitation appropriately.",
        "thermal inhalation burns": "cooled mist or aerosol therapy may reduce minor edema. ice placed to the throat may reduce swelling. intubation may be needed if supraglottic tissue swelling threatens the patients airway. laryngospasms and bronchospasm may occur.",
        "chemical burns of the skin": "remove the chemical from the body quickly. rinse of liquid chemicals with copious quantities of water. remove the patients clothing, including shoes and socks because chemicals can collect. after the first initial decontamination, wash the body again with a mild detergent (dishwashing liquid) to insure that that chemical comes off. make sure to do so gently as to not damage the skins integrity further. after getting the chemical off of the body, prevent hypothermia and keep the patient warm. brush off power chemicals.",
        "chemical burns to the respiratory system": "potential airway compromise and worsening airway condition may occur. it is important to maintain oxygenation and airway stability. aerosolized beta-agonist are usually helpful.",
        "chemical burns to the eyes": "flush the eyes with copious amounts of water. if the patient wears contact lenses, irrigate the eyes for 1-2 minutes. once completed have the patient remove the contact lenses, and continue to rinse the eyes. cover the eyes with gauze and transport.",
        "electrical burn or injury management": "treat life-threatening injuries. cardiac dysrhythmia may occur and need to be treated accordingly. these patients may be in extreme pain and may be unresponsive to pain management. if the patient has been struck by lightning, it is important to note that the heart may resume function shortly after impact or after cpr that has been started immediately following the strike. airway obstruction, respiratory arrest, and cardiac arrest are common and need to be treated quickly. cervical spinal injuries may be present. avoid hyperextension of the neck and a jaw thrust maneuver is recommended.",
        "radioactive injuries": "decontamination is vital. irrigate open wounds. avoid washing the skin because this could lead to radioactive substances being internally absorbed. you may need to treat radioactive burns as you would chemical burns. remove the patient from the potential source as quickly as possible this can also help reduce the overall amount of exposure absorbed into the body.",
        "definitive burn care": "initial evaluation and resuscitation will occur in the first 72 hours of the burn patients arrival to the hospital. initial resuscitation efforts with be initiated. ensuring that the patient has a secure airway will take place along with determining the need for an advanced airway management. achieve accurate fluid resuscitation and adjust according. a thorough evaluation of the patient will occur. initial wound excision and biologic closure will occur within 1-7 days of the patient being in the hospital. full-thickness wounds will be identified and removed. obtain biologic closure will be done. definitive wound closure occurs from 7 days to 6 weeks of the patient being in the hospital. temporary coverings will be replaced with definitive ones. the closure of small and complex wounds will take place. rehabilitation, reconstruction, and reintegration with occur throughout the patients entire hospitalization assessments will be performed on range of motion and improving such along with reducing edema. the patient will undergo strengthening, rehabilitation, and mobility treatment to prepare the individual to return to the community.",
        "acute radiation syndrome": "causes hematologic, central nervous system, and gastrointestinal changes over a period of time that may not be witnessed by initial ems interaction. if the patient has been rendered unresponsive by radiation or vomited within 10 minutes of exposure will not survive. vomiting in less than an hour after exposure are considered to have experienced a severe exposure. these individuals have a 30-80% change of survival. vomiting within 1-2 hours after exposure means that these patients have 95-100% of survival.",
        "radiation contact burns": "can cause a local soft-tissue injury. resembling a superficial sunburn to a chemical burn. typically these injuries will appear within hours to days of the exposure."
    },
    {
        "introduction": "the recognition and management of hemorrhage in medical and trauma patients are vital for decreasing mobility and mortality. there is a significant emphasis on hemorrhage management in trauma that should be managed after, or at the same time if resources allow, airway management is completed.",
        "anatomy & physiology": "structures of the heart located inside the thoracic cavity behind the sternum with about two thirds of the heart lying in part of the left aspect of the mediastinum. consisting of the right atrium and ventricle that supplys blood to the lungs and receives the blood from the systemic vasculature. also containing the left atrium and ventricle that supplys blood to the systemic circulation and receives the blood from the pulmonary circulation. blood will pass between the right atrium and right ventricle via the tricuspid valve. where the right ventricle will pump the blood up through the pulmonary semilunar valve. blood will pass between the left atrium and left ventricle via the mitral valve. where the left ventricle will pump the blood up through the aortic semilunar valve.",
        "blood flow within the heart and lungs": "the superior and inferior vena cava return blood from the systemic circulation that is deoxygenated to the right atrium. from here the blood will pass between the right atrium into the ventricle to be pumped into the pulmonary circulation. once the blood is in the pulmonary circulation the blood will offload the carbon dioxide and on-load oxygen for perfusion of the bodies cells. blood will be returned to the left side of the heart to then be pumped around to systemic circulation.",
        "the cardiac cycle": "is used to describe the continual progressive and repetitive pumping of the heart. it is important to remember that is is controlled by the sa and av node. starting with the depolarization of the right atrium and left atrium that forces the blood into the prospective ventricles. with the next aspect being the depolarization of the right ventricle and left ventricle forcing the blood into the prospective section of circulation. preload is at the amount of blood that is returned to the heart to be pumped out. this directly affects the after-load. after-load is the pressure in the aorta or peripheral vasculature that the left ventricle must pump against. the greater the after-load the harder it is for the ventricle to eject blood. stoke volume is the amount of blood ejected per contraction. this can be reduced in the presence of high after-load. cardiac output is the amount of blood pumped through the circulatory system in 1 minute. this is calculated by multiplying the stroke volume and pulse rate.",
        "blood": "plasma is the straw colored fluid that counts for more than half of the total blood volume. consisting of 92% of water and 8% of dissolved chemicals, minerals, and nutrients. red blood cells (rbcs) make up about 45% of the blood volume. the purpose of the cells are to carry oxygen, glucose, proteins, fats, and electrolytes to the tissues and then carry away cellular waste products. these cells are also known as erythrocytes. hemoglobin is contained on the cells and binds to oxygen. each is able to bind up to four gaseous molecules. white blood cells (wbcs) combined with platelets only makes up about 1% of the blood volume. help to fight infections. also know as leukocytes. there are several types and they all sever different functions. platelets is import for controlling bleeding. these small cells are vital for coagulation to take place. working with clotting proteins, calcium, and other proteins in order to stop the hemorrhage. hematocrit tests are vital in order to ensure the patient has the appropriate level of rbcs that can indicate disease states or conditions. normal range for males of any age is 40.7-50.3% for females of any age it is 36.1-44.3%.",
        "blood circulation and perfusion": "it is important to remember that arteries carry blood away from the heart while veins carry blood to the heart. the vasculature that is spread throughout the body is extensive with varying branches and connection points supplying vital nutrients to the body that is needed for life. perfusion is the actual circulation of blood within an organ or tissue in adequate amounts to meet the cells needs. the autonomic nervous system monitors the bodies needs and adjust the blood flow accordingly.",
        "pathophysiology of hemorrhage": "external hemorrhage the severity of hemorrhage is linked to the wound type and the types of vascular that have been injured. capillary bleeding is typically described as oozing and hemorrhage can be of a significant amount in the present of a large abrasion and varicose veins. arterial bleeding is typically described as spurring (initially), with the progression of loss of blood the bleeding may continue to a simple continual flow of blood. the blood is typically described as bright red due to being of high concentration of oxygen. this type of bleeding changes along with blood pressure. arterial incisions directed across or transverse will often recoil in an attempt to slow the bleeding. if the artery is cut vertically it will continue to bleed and no longer has the mechanism to attempt to self control. venous bleeding is typically described as dark red due to the low oxygen concentration and is a steady flow.",
        "internal hemorrhage": "internal hemorrhage may occur in any location of the body, with some being contained within a small space and other being able to freely bleed. fractures of the long bones can still lose blood, but is confined into the space surround the bones and between the muscle tissues. occupying a limited space. hemorrhage into the trunk of the body can be considerable and develop rapidly. leading too severe and uncontrollable bleeding in the out of hospital setting. non trauma induced hemorrhage usually occurs in the gi system. but can also occur in the pelvic cavity or abdominal cavity due to ectopic pregnancy, abdominal cavity and thoracic cavity or inside the cranium due to ruptured aneurysms.",
        "the significance of hemorrhage": "the adult male has approximately 70ml of blood per kg of body weight, adult females contain approximately 65ml of blood per kg. the body cannot tolerate more than 20% of the total blood volume. if the body loses more than 20% of blood, vital signs will change leading to increased heart rate, respiratory rate, and a decrease in blood pressure. with pediatrics, they have a significantly less blood volume meaning that with even a small amount of blood loss could lead to significant changes.",
        "physiologic response to hemorrhage": "with arterial bleeding it can be difficult to control due to the pressure that cause the bleeding to spurt. as the bleeding continues the amount of blood available decreases causing the patient blood pressure to drop. this can be seen when the spurring diminishes. venous bleeding is easier to manage due to having less pressure. capillary bleeding is typically relatively easy to slow and stop.",
        "hemorrhagic shock": "there is significant risk of developing hemorrhagic shock in patients with both external and internal hemorrhage. with an increased risk of development in patients with trauma and internal hemorrhage. penetrating injuries to the heart, thoracic vascular system, abdominal vascular system, venous system, and liver have a high potential for development of hemorrhagic shock.",
        "management for hemorrhage and hemorrhagic shock": "external hemorrhage initially management includes applying direct pressure over the site of bleeding and maintaining said pressure. it is important to recognize the need for a secondary method of hemorrhage control included below. rapid transport is recommended for patients who are presenting with hypopurfusion with shock management."
    },
    {
        "introduction": "abdominal trauma patients can be difficult to evaluate, manage, and treat. trauma is rarely resolved in the prehospital setting. the abdominal cavity is a dangerous place to sustain trauma, containing vital organs and structures. the national center for injury prevention and control reports that trauma is the leading cause of death in people 1-44 years of age. genitourinary trauma is found in 10-20% of major trauma patients with 2-5% in all trauma patients.",
        "anatomy & physiology": "right upper quadrant: contains the majority of the liver, right kidney, colon, a small portion of the pancreas, gallbladder, and small intestine. left upper quadrant: contains a small portion of the liver, spleen, left kidney, stomach, colon, majority of the pancreas, and small intestine. right lower quadrant: contains the colon, small intestine, right ureter, and appendix. in females, it also contains the right ovary and fallopian tube. left lower quadrant: contains the colon, small intestines, and left ureter. in females, it also contains the left ovary and fallopian tube.",
        "additional important areas": "peritoneal space: upper is covered by the lower part of the thorax. contains the diaphragm, liver, spleen, stomach, gallbladder, and transfers colon. lower is encased in the peritoneum. contains the small bowel, sigmoid colon, parts of the descending and ascending colon. in females it also contains the reproductive organs. retroperitoneal space: sits behind the peritoneal lining of the abdomen. contains the abdominal aorta, inferior vena cava, pancreas, kidney, and ureters. contains parts of the duodenum, descending, and spending colon.",
        "organs": "solid organs of the abdominal cavity: the liver is the largest organ of the abdomen. containing a significant amount of blood supply from the hepatic artery and the hepatic-portal vein. about 13% of the body's blood supply is contained in the liver. liver hemorrhage is difficult to control and most patients require blood transfusions. the liver detoxifies the blood, processes hemoglobin before it is stored or used, regulates blood clotting, produces immune factors, removes bacteria from the bloodstream, and plays an important role in regulating fats.",
        "hollow organs of the abdominal cavity": "the stomach is connected to the esophagus. comprised of 3 walls that contain contains the food and liquids ingested. blood is brought to the stomach via the relic trunk and returned by the portal vein. is regulated via impulses from the sympathetic and parasympathetic nerves. contains acid that is used for digestion and contains a ph of 1.5-3.",
        "genitourinary system organs": "the kidneys rest in the retroperitoneal space. they filter the blood and excrete waste products from the body. the ureters are thick-walled hollow tubes that carry the urine produced by the kidneys to the bladder.",
        "female reproductive organs": "the uterus is located in the pelvic cavity behind the urinary bladder. this organ provides the location for implantation, growth, and nourishment for a fetus during pregnancy. the uterus will increase in size during pregnancy as the fetus develops, which can be extremely dangerous if the patient sustains trauma.",
        "other": "periumbilical area is the region surrounding the umbilicus. peritoneum is the lining of the abdominal cavity. mesentery is the membranous double fold of tissue in the abdomen that keeps organs attacked to wall.",
        "physiology": "the internal body cavities including the abdominal, retroperitoneal, and muscle compartments from the connection of the lower extremities to the core can provide collection points where blood can collect. leading to shock.",
        "mechanisms of injury": "blunt trauma is two-thirds of all trauma, and can cause compression, shearing, and crushing injury patterns. compression or deceleration forces can lead to closed abdominal injuries.",
        "motor vehicle crashes": "seat belt injuries: if the seat belt is too high it can lead to squeezing of abdominal organs and the great vessels in sudden stops or deceleration.",
        "falls": "it is extremely important to determine the body position upon impact because this information can provide you with an idea of what injuries the patient has sustained.",
        "blast injuries": "can be seen in mines, shipyards, chemical plants, military activity, and even in the event of a terrorist activities.",
        "types of injuries": "evisceration: occurs when the abdominal organs protrude through a wound in the abdominal wall.",
        "impaled objects": "stabilize the impales object and transport the patient in the position they were found in.",
        "solid organ injuries": "when a solid organ has become injures it can leak blood into the abdominal cavity causing nonspecific signs like tachycardia and hypotension.",
        "liver injuries": "due to the liver size, location, and receiving 25% of the cardia output liver injuries are common and problematic.",
        "spleen injuries": "falls and motor vehicle crashes are common causes of spleen injuries, but they can even occur in minor acts of traumatic mechanisms.",
        "pancreas injuries": "occurs in less than 5% of all major abdominal trauma, due to its position in the body and being protected by other abdominal trauma.",
        "diaphragm injuries": "any injury will present with signs and symptoms of ventilatory compromise.",
        "hollow intraperitoneal organ injuries": "most symptoms created by hollow organ injuries are due to the peritoneal linings becoming inflamed or irritated due to the spilling of the contents contained within the organs themselves.",
        "small and large intestine injuries": "most commonly injured organs in penetrating trauma and can be injured in severe blunt trauma.",
        "stomach injuries": "penetrating trauma is the common cause of injuries.",
        "retroperitoneal injuries": "injuries to the organs contained in the retroperitoneal space can be very difficult to diagnose.",
        "vascular injuries": "blunt and penetrating trauma can lead to injuries to the vascular structures in the abdomen, with penetrating trauma being the major cause.",
        "duodenal injuries": "duodenal injures are usually attributed to high-speed deceleration injuries leading to contents being spilled into the abdominal cavity.",
        "kidney injuries": "injures to the kidney occur in less than 5% of all trauma patients with three fourths of the patients being under the age of 45.",
        "bladder and urethra injuries": "ureteral injuries are extremely difficult to diagnose in the ems setting and rarely lead to an immediate life-threatening condition.",
        "male genitalia injuries": "testicular or scrotal sac injuries: severe injuries to the testicles are rare due to their mobility and natural position.",
        "female genitalia injuries": "vaginal trauma can be caused by blunt or penetrating trauma and may be self-inflicted.",
        "management": "it is extremely important to have a high index of suspicion of abdominal organ injury in the presence of moi that suggests the risk of significant internal organ injury."
    },
    {
        "document title": "Adult Trauma Patient Care",
        "protocol title": "Injury \u2013 Head",
        "overview": "Brain injury and its accompanying pathological processes continue to be a leading cause of mortality associated with trauma. Whether the injury is due to a blunt or penetrating mechanism, bleeding or swelling of the brain and surrounding tissue may lead to an increase in pressure within the cranial cavity, known as intracranial pressure (ICP). If pressure within the skull is not controlled, neurologic changes may produce signs and symptoms ranging from headache to coma with loss of protective reflexes. Blunt force trauma may result in scalp injury, skull fracture, and meningeal and brain tissue injury. Penetrating trauma may produce focal or diffuse injury, depending on the velocity of the penetrating object. Although the pre-hospital provider cannot reverse the brain tissue damage from the initial/primary brain injury that has already occurred, they can play a major role in preventing or limiting the processes that exacerbate and lead to a secondary brain injury. The pre-hospital provider\u2019s goal is to focus on reversing any hypoxia, hypotension, hypercarbia, acidosis, or increasing intracranial pressure.",
        "hpi signs and symptoms": "* Time of injury\n* Mechanism: blunt vs penetrating\n* Loss of consciousness\n* Bleeding\n* Medical history\n* Medications\n* Evidence of multi-system trauma\n* Pain, swelling, bleeding\n* Altered mental status, unconsciousness\n* Respiratory distress, failure\n* Cushing\u2019s reflex triad\n* Cheyne-Stokes and Biot\u2019s respirations\n* Unequal, dilated, sluggish pupil(s)\n* Vomiting\n* Significant mechanism of injury",
        "considerations": "* Skull fracture\n* Brain injury (concussion, contusion, hemorrhage, laceration)\n* Epidural hematoma\n* Subdural hematoma\n* Subarachnoid hemorrhage\n* Spinal injury\n* Falls\n* Seizure disorder\n* Abuse",
        "procedure": "1. Perform general patient management.      \n2. Support life-threatening problems associated with airway, breathing, and circulation.      \n3. Administer oxygen to maintain SpO2 94 - 99%.  Consider supporting respirations with a BVM.       \n4. Assess patient and mechanism of injury to determine need for Spinal Motion Restriction (4.13)      \na. If patient requires SMR, assess and document PMS in all extremities before and after movement.      \n5. Obtain and document baseline GCS and reassessments.      \n6. Monitor capnography, if available.  Attempt to maintain between 35  - 45 mm Hg.     \n7. Place patient on cardiac monitor.      \n8. Establish an IV of normal saline at KVO.  If time permits, establish an additional line.       \n9. Obtain a blood glucose sample.      \n10. If patient is exhibiting signs of shock, refer to Shock protocol.       \n11. Transport and perform ongoing assessment as indicated.",
        "pearls": "1. Hyperventilation is not recommended for head-injury patients who do not have symptoms of herniation syndrome, as auto-regulatory mechanisms are intact and hyperventilation may worsen cerebral perfusion pressure.\n2. One of the most important indicators of worsening head injury is a change in LOC and/or GCS. \n3. Increased ICP may cause hypertension and bradycardia (Cushing\u2019s response). \n4. Hypotension usually indicates injury or shock unrelated to the head injury and should be treated aggressively to maintain adequate cerebral perfusion.\n5. Supine positioning may also increase ICP transiently.\n6. Ensure that neck collars are not too tight as to restrict venous drainage."
    },
    {
        "document title": "Adult Trauma Patient Care",
        "protocol title": "Injury \u2013 Electrical Injuries",
        "overview": "Before treating any patient with an electrical injury, ensure your personal safety. Do not touch the patient if the patient is still in contact with the electrical source. The vast majority of electrical injuries are caused by generated electricity, such as that encountered in power lines and household outlets. Relative to the external damage caused by electrical injuries, internal damage is often more severe, and can include damage to muscles, blood vessels, organs, and nerves. Damaged muscle releases myoglobin which can cause acute renal failure. Electrical current as low as 20 mA can cause respiratory arrest and as little as 50 mA can cause ventricular fibrillation. Although long-bone fractures and spinal injuries can occur due to falls after electrocution, they can additionally occur due to severe tetanic muscle spasms with high amplitude electrocutions.",
        "hpi": "Lightning or electrical exposure\n Single or multiple victims\n Trauma secondary to fall from high wire or MVC into line\n Duration of exposure\n Voltage and current (AC / DC)",
        "signs and symptoms": "Burns\n Pain\n Entry and exit wounds\n Hypotension and shock\n Cardiac and/ or respiratory arrest",
        "procedure": "1. Perform general patient management. Do not touch the patient if they are in contact with the electrical source.     \n2. Support life-threatening problems.     \n3. Administer oxygen to maintain SPO2 94 - 99%. Consider supporting respirations with a BVM.     \n4. Determine extent of any burn injuries. Refer to the Injury \u2013 Burns \u2013 Thermal protocol. Avoid initiating IVs in areas of burn unless absolutely necessary.    \n5. Place patient on cardiac monitor; obtain 12 Lead ECG.    \n6. Interpret ECG. Refer to the appropriate Cardiac Care protocol for dysrhythmias. If hyperkalemia is suspected, contact Medical Control.  \n7. Establish an IV of normal saline at KVO.   \n8. Consider administration of pain management per General \u2013 Pain Control protocol.   \n9. Transport to a trauma facility and perform ongoing assessment as indicated.",
        "detailed considerations": "The cutaneous system is typically involved in electrocution. Importantly, the initial size of the burn site is not an accurate reflection of the amount of tissue actually involved because the subcutaneous tissue is commonly involved. Therefore, the rule of nines should not be used for calculating fluid resuscitation. Instead, adequate tissue perfusions, vital signs, and urine output should guide fluid resuscitation.\nAn electrical injury should be treated more like a crush injury rather than a thermal injury. Fluid resuscitation should begin as soon as possible to maintain a urinary output of 0.5 to 1 mL / kg / hr.",
        "pearls": "1. Ventricular fibrillation and asystole are the common presenting dysrhythmias associated with electrical injuries.\n2. Injuries are often hidden. The most severe injuries will occur internally in the muscles, vessels, organs, and nerves.\n3. If the victim did not arrest initially, the probability of ROSC and survivability can be higher in lightning strike injuries.\n4. Do not overlook other trauma (i.e., falls).\n5. Lightning is a massive DC shock most often leading to asystole as a dysrhythmia.\n6. In lightning injuries, most of the current will travel over the body surface producing flash burns over the body that appears as freckles.\n7. Do not overlook the possibility of spinal injuries or long bone fractures associated with lightning strikes, primarily the cause of trauma or tetanic muscle contractions."
    },
    {
        "document title": "Adult Trauma Patient Care",
        "protocol title": "Traumatic Cardiac Arrest",
        "overview": "Survival from traumatic cardiac arrest is poor. Ideally, the clinical care of patients in traumatic arrests should be managed in the field until ROSC or termination of efforts. The distance from the level 1 or 2 trauma center may influence transport decisions. Transport times greater than 15 minutes to the trauma center should be managed in the field unless extenuating circumstances exist. The following algorithm is intended as a guideline in conjunction with Protocol 12-9.",
        "pearls": "1. The traditional use of 14-gauge IV catheters at the standard midclavicular line has been questioned. Consider anterior mid-axillary placement for larger adults.\n2. Penetrating vs. blunt traumatic cardiac arrest: Penetrating trauma outcomes are generally better than blunt traumatic arrest outcomes.\n3. AHA Guidelines for CPR and Emergency Cardiovascular Care make no mention of ACLS drugs in the section on cardiac arrest associated with trauma. Use should be limited to a single early dose in traumatic arrests.\n4. Medical Direction emphasizes managing external hemorrhaging, establishing an airway, needle decompression as needed, high-quality chest compressions, and defibrillation.\n5. Priority of transport destination for traumatic arrest:\n\u2022 Level 1 Trauma Center\n\u2022 Level 2 Trauma Center\n\u2022 Level 3 Trauma Center\n\u2022 Closest Appropriate Facility\n6. Consider continuous scene safety and security in transport decisions."
    },
    {
        "document title": "Adult Trauma Emergencies",
        "protocol title": "Injury \u2013 Burns - Thermal",
        "overview": "Burns are a devastating form of trauma associated with high mortality rates, lengthy rehabilitation, cosmetic disfigurement, and permanent physical disabilities. Thermal, chemical, electrical, nuclear radiation, or solar sources may cause burns. Burns can affect more than just the skin. They can affect the body's fluid and chemical balance, temperature regulation, and musculoskeletal, circulatory, and respiratory functions.\n\nBurns are classified by degree, 1\uf0b0 (superficial) some reddening to skin, 2\uf0b0 (partial thickness) has blistering and deep reddening to the skin, and 3\uf0b0 (full thickness) causes damage to all skin layers and is either charred/black or white/leathery with little or no pain at the site. The patient's palm equals 1% of body surface area when determining the area affected. This is sometimes more helpful than using the \"rule of nines\" especially with pediatric patients.",
        "hpi": "* Type of exposure (heat, gas, chemical)\n* Inhalation injury\n* Time of injury\n* Past medical history\n* Medications\n* Other trauma",
        "signs and symptoms": "* Burns, pain, swelling\n* Dizziness\n* Loss of consciousness\n* Hypotension/shock\n* Airway compromise, distress\n* Singed facial or nasal hair\n* Hoarseness, wheezing",
        "considerations": "* Chemical\n* Thermal\n* Radiation\n* Electrical",
        "procedure": "1. Stop the burning process\n    * Thermal burns: Irrigate the burned area with sterile water or saline to cool skin. Do not attempt to wipe off semisolids (grease, tar, wax, etc.). Do not apply ice. Dry the body when the burn area is greater than or equal to 10% TBSA to prevent hypothermia.\n    * Dry chemical burns: Brush off dry powder, then lavage with copious amounts of tepid water (sterile, if possible) for 20 minutes. Continue en route to the hospital.\n    * Liquid chemical burns: Irrigate the burned area with copious amounts of tepid water (sterile, if possible) for 20 minutes. Continue en route to the hospital.\n2. Perform general patient management.\n3. Support life-threatening problems associated with airway, breathing, and circulation.\n4. Administer oxygen to maintain SPO2 94-99%\n5. If the patient is in critical respiratory distress or impending respiratory failure, consider placement of orotracheal intubation.\n6. Remove clothing from around burned area, but do not remove/peel off skin or tissue. Remove and secure all jewelry and tight fitting clothing.\n7. Assess the extent of the second/third degree burn (BSA). If more than 20% (2nd and 3rd) BSA, establish IV and administer NS\n    * If patient is less than 5 years of age, infuse 125mL/hr\n    * If patient is 5-14 years of age, infuse 250 mL/hr\n    * If patient is greater than 14 years of age, infuse 500mL/hr.\n8. Cover the burned area with a clean, dry dressing. Wet dressing may be used if the burned TBSA is less than 10%.\n9. For pain control, refer to Pain Management Protocol.\n10. Maintain body temperature and reassess patient\n11. Transport to closest appropriate facility. See BURN UNIT REFERRAL CHART\n\nNormal Saline or Lactated Ringers are fluids of choice in burn patients.",
        "american burn association burn unit referral criteria": "* Partial thickness and full thickness burns greater than 10% of the total body surface area (TBSA) in patients under 10 or over 50 years of age.\n* Partial thickness burns and full thickness burns greater than 20% TBSA in other age groups.\n* Partial thickness and full -thickness burns involving the face, eyes, ears, hands, feet, genitalia or perineum or those that involve skin overlying major joints.\n* Full-thickness burns greater than 5% BSA in any age group.\n* Electrical burns, including lightning injuries; (significant volumes of tissue beneath the surface may be injured and result in acute renal failure and other complications).\n* Significant chemical burns.\n* Inhalation injuries.\n* Burn injury in patients with pre-existing illness that could complicate management, prolongs recovery, or affects mortality.\n* Any burn patient in whom concomitant trauma poses an increased risk of morbidity or mortality may be treated initially in a trauma center until stable"
    },
    {
        "document title": "Adult Trauma Patient Care",
        "protocol title": "Injury - Thoracic",
        "overview": "Thoracic injuries can be dramatic, presenting with obvious physical findings that lead to immediate identification and management during the initial assessment, while others may only exhibit subtle signs and symptoms that can be easily missed initially. A high index of suspicion, accurate assessment, and frequent reassessment are necessary to identify both the apparent and less obvious thoracic injuries that could lead to lethal consequences. Thoracic injury may result from both penetrating and blunt trauma. Penetrating trauma has a tendency to be more obvious due to the presence of an open wound while blunt trauma may produce findings such as large contusions, tenderness, fractured ribs or flailed segments, or relatively little external evidence of injury. Although little external injury may be present, the patient may be suffering from multiple and severe organ, vascular, and structural injuries.",
        "hpi": "* Time of injury\n* Mechanism: blunt vs penetrating\n* Loss of consciousness\n* Damage to structure, vehicle\n* Location in structure or vehicle\n* Speed, details of MVC: Restraints, protective devices\n* Medical history\n* Medications\n* Evidence of multi-system trauma",
        "signs and symptoms": "* Pain, swelling, bleeding\n* Deformity, lesions\n* Altered mental status, unconsciousness\n* Respiratory distress, failure\n* Hypotension, shock\n* Arrest\n* Significant mechanism of injury",
        "considerations": "* Tension pneumothorax\n* Flail chest\n* Pericardial tamponade\n* Open chest wound\n* Hemothorax",
        "procedure": "1. Maintain scene and provider safety.\n2. Perform general patient management.\n3. Administer oxygen, to maintain SPO2 94-99%. If needed, assist ventilations with BVM, maintain C-spine precautions.\n4. If airway remains unstable, consider placement of definitive airway (Supraglottic / dual lumen) (ETT I and P only).\n5. Identify mechanism of injury.\n6. Assess breath sounds. Stabilize any chest injuries.*\n7. If patient has clinical findings consistent with tension pneumothorax and has hypotension/signs of shock, perform needle decompression* per protocol.\n8. Establish large bore IV\u2019s of normal saline. Titrate to systolic blood pressure of 90 to 100 mmHg.\n9. Place patient on cardiac monitor per assessment.\n10. Treat pain if indicated. Refer to pain management protocol.\n11. Transport to the appropriate hospital per trauma triage scheme and reassess patient as indicated.",
        "pearls": "1. The amount of external bleeding is not an indicator of the potential severity of internal bleeding associated with an underlying trauma.\n2. Some injuries, such as simple rib fractures, may produce such excruciating pain that the patient intentionally hypoventilates to reduce chest wall movement, causing secondary hypoxia.\n3. Due to the amount of external noise, a possible pneumothorax should not be determined by lung sounds alone. In the presence of a true tension pneumothorax, the patient will also show signs of increasing tachycardia, decreasing SpO2, tachypnea, and anxiety. Tracheal deviation away from the affected side is a late sign and may be difficult to assess in obese patients.\n4. Careful reassessment of lung sounds should occur continuously. A patient that initially only has an open pneumothorax may quickly develop a tension pneumothorax and need needle thoracentesis after an occlusive dressing has been applied.\n5. A true flail segment is two or three adjacent ribs, fractured in two or more places, which have the ability to move independently of the remaining chest wall.\n6. Although paradoxical motion is often thought to be the hallmark sign of a flail chest, when the ribs fracture, the intercostal muscles may spasm, causing the flail segment to be initially stabilized. Paradoxical motion may be initially missed upon inspection while a thorough palpation exam will reveal any instability.\n7. Stabilizing a flail segment with sandbags or other devices is no longer recommended. Carefully monitor for inadequate ventilations and provide positive pressure ventilations as needed."
    },
    {
        "document title": "Adult Trauma Patient Care",
        "protocol title": "General \u2013 Neglect or Abuse Suspected",
        "overview": "Child and elder abuse, which includes sexual abuse, physical abuse, and neglect is SUSPECTED ABUSE/NEGLECT often overlooked and under-reported. It is the ethical and legal responsibility to notify the receiving hospital of suspicions of child and elder abuse. It may prevent serious injury and death. Proof of abuse is not needed to make the report to hospital, CPS, APS, or social services. Patterns of abuse can reflect any form of physical and/ or mental trauma but are usually characterized by unexplained or poorly explained injuries of different ages and delay in seeking medical care. There are often no external signs of injuries. The provider should note vague medical symptoms such as repeated vomiting, abdominal pain, and distention in an elderly person with other evidence of abuse. Also be observant of decubitus ulcers, unsanitary conditions, skin conditions and the general nourishment of the elder. Observation, transport, and reporting are the key responsibilities of the pre-hospital provider",
        "hpi": "Time of injury\nMechanism: blunt vs penetrating\nLoss of consciousness\nBleeding\nPast medical history\nMedications\nEvidence of multisystem trauma",
        "signs and symptoms": "Pain, swelling, bruising, bleeding\nAltered mental status, unconsciousness\nRespiratory distress, failure\nDehydration\nFractures\nDecubitus",
        "considerations": "Major traumatic mechanism of injury\nSkull fracture\nBrain injury (concussion, contusion, hemorrhage, or laceration)\nEpidural hematoma\nSubdural hematoma\nSubarachnoid hemorrhage\nSpinal injury",
        "procedure": "1. Perform general patient management. \n2. Support life-threatening problems; C-spine precautions. \n3. Administer oxygen, to maintain SPO2 94-99% Support respirations as necessary with a BVM. \n4. Observe and record objectively the surroundings and conditions of the scene and patient. \n5. Refer to the appropriate Medical or Trauma Patient Care protocol for obvious injuries / illnesses.\n6. UNDER VIRGINIA LAW, EMS PROVIDERS ARE MANDATORY REPORTERS OF SUSPECTED ELDER AND CHILD ABUSE.\na. For children, notify the Emergency Department attending physician and Child Protective Services, if needed.\nb. For adults, Adult Protective Services, or Social Services as appropriate\n7. Transport as soon as possible."
    },
    {
        "document title": "Adult Trauma Patient Care",
        "protocol title": "Hemorrhage Control",
        "overview": "When treating soft tissue injuries, control of blood loss, prevention of shock, and decontamination of affected areas take priority. Unless you note extensive bleeding, wound management by dressing and bandaging is a late priority in the care of trauma patients. Dress and bandage wounds whose bleeding does not represent a life threat only after you stabilize your patient by caring for higher priority injuries.",
        "hpi": "* Time of injury\n* Mechanism: blunt vs penetrating\n* Significant mechanism of injury\n* Loss of consciousness\n* Medical history\n* Medications (anticoagulants)\n* Evidence of multi-system trauma",
        "signs and symptoms": "* Pain\n* Swelling\n* Deformity\n* Lesions\n* Respiratory distress or failure\n* Hypotension or shock\n* Cardiac arrest",
        "considerations": "* Arterial versus venous bleeding",
        "procedure": "1. Maintain scene and provider safety.\n2. Ensure appropriate PPE is donned to limit potential exposure to bloodborne pathogens.\n3. Perform general patient management.\n4. Support life-threatening problems.\n5. Apply oxygen to maintain pulse ox 94-99%. If indicated, support respirations with a BVM.\n6. With a gloved hand, apply direct pressure with a dressing to the site of hemorrhage.\n7. If serious hemorrhage persists, expose the wound and place digital pressure with a gloved hand on the site of bleeding.\n  a. If bleeding controlled, bandage the dressing in place, maintaining pressure on the wound.\n8. For uncontrolled life threatening bleeding of an extremity, consider application of a TOURNIQUET.\n9. If extremity bleeding still uncontrolled:\n  a. Consider application of a second tourniquet proximal to the first.\n  b. Consider applying hemostatic gauze or packing to wound.\nA B EN I P\n10. If patient shows signs of hypoperfusion, refer to Protocol 3-13: Hypotension/Shock.\n11. Transport to closest appropriate facility and perform ongoing assessment as indicated.",
        "pearls": "1. The amount of external bleeding is not an indicator of the potential severity of internal bleeding associated with an underlying trauma."
    },
    {
        "document title": "Adult Trauma Emergencies",
        "protocol title": "Injury \u2013 Abdominal Trauma (Protocol 4-2)",
        "overview": "Blunt and penetrating traumas are major causes of morbidity and mortality in the United States. In blunt force abdominal trauma, the spleen and liver are typically the most commonly injured organs, and in penetrating trauma, there is a slightly higher mortality, depending on the mechanism of injury. Gunshot and stab wounds combine to make up the largest percentage of penetrating abdominal injuries. When performing a focused abdominal assessment, be organized, efficient, and thorough. Initial abdominal examinations only identify injury about half the time; secondary exams are needed when there is a high index of suspicion for abdominal trauma. A proper abdominal examination involves exposing the entire abdomen from the nipple line to the groin and using a standard examination sequence of inspection, auscultation, percussion, and palpation.",
        "hpi": "* Time of injury\n* Mechanism: blunt/penetrating\n* Loss of consciousness\n* Damage to structure, vehicle\n* Location in structure or vehicle\n* Speed details of MVC\n* Restraints, protective devices\n* Medical history\n* Medications",
        "signs and symptoms": "* Evidence of multi-system trauma\n* Pain, swelling, bleeding\n* Deformity, lesions\n* Altered mental status, unconsciousness\n* Respiratory distress, failure\n* Hypotension, shock\n* Arrest",
        "considerations": "* Significant mechanism of injury\n* Intra-abdominal bleeding\n* Pelvis fracture\n* Abuse",
        "procedure": "1. Maintain scene and provider safety.     \n2. Perform general patient management.     \n3. Administer supplemental oxygen to maintain a SPO2 94 - 99%. If needed assist ventilations with BVM but avoid hyperventilation, maintain C -spine precautions.     \n4. Identify mechanism of injury.     \n5. Establish large bore IV\u2019s of normal saline. Titrate to systolic blood pressure of 90 to 100 mmHg.   \n6. Treat pain if indicated. Refer to General \u2013 Pain Control protocol.   \n7. Consider ONDANSETRON (ZOFRAN) 0.1 mg / kg slow IVP over 2 - 5 minutes, max 4.0 mg per dose as needed per Medical \u2013 Nausea/Vomiting protocol. Do not give PO meds.   \n8. Transport to the appropriate hospital per Field Trauma Triage Scheme.    \n9. Reassess patient as indicated.",
        "impaled objects": "* Stabilize impaled objects in place with bulky dressings.",
        "severe hemorrhage from open penetrating injury": "* Control bleeding with well-aimed direct pressure directly on the bleeding source.\n* Once controlled, apply dry, sterile dressing.",
        "evisceration with protruding abdominal contents": "* Loosely wrap any protruding abdominal contents with a sterile dressing moistened with warm (if available) Normal Saline and cover in entirety with an occlusive dressing.",
        "pearls": "1. The amount of external bleeding is not an indicator of the potential severity of internal bleeding associated with an underlying trauma.\n2. Avoid overly aggressive fluid administration; provide fluid boluses to maintain systolic BP between 90 \u2013 100 mmHg ; alternatively, a mean arterial pressure of 65 mmHg is equally desirable. MAP is approximately equal to : Diastolic BP + 1/3 (Systolic BP - Diastolic BP)\n3. Abdominal eviscerations are a surgical emergency. The protruding organ requires careful cleaning and evaluation prior to reinsertion. Do not attempt to reinsert the organs in the prehospital setting.\n4. Impaled objects in the abdomen often tamponade internal hemorrhage, and removing them may trigger significant internal bleeding. Remember that any bump against the object moves the distal end in the organ and may worsen damage.\n5. Pain management is an essential component to good trauma care. Simple pain management techniques include oxygen administration, splinting, speaking in calm, reassuring voice, and placing the patient in his or her position of comfort. When spinal immobilization is required, flexing the patient's knees toward the chest helps relax the abdominal muscles."
    },
    {
        "document title": "Adult Trauma Emergencies",
        "protocol title": "Injury \u2013 General Trauma Management",
        "overview": "Each year, one out of three Americans sustains a traumatic injury. Trauma is a major cause of disability in the United States. According to the Centers for Disease Control (CDC) in 2008, 118,021 deaths occurred due to trauma. Trauma is the leading cause of death in people under 44 years of age, accounting for half the deaths of children under the age of 4 years, and 80% of deaths in persons 15 to 24 years of age. As a responder, your actions within the first few moments of arriving on the scene of a traumatic injury are crucial to the success of managing the situation. Within these moments, you must size up the situation, mitigate as many hazards as possible, establish incident command, rapidly triage patients and ultimately assess, treat and extricate patients from the scene. In doing so, you must decide when to extricate a patient and what treatment is essential to improve the patient's chances of survival, based on your knowledge, previous experience and a problem-based assessment algorithm.\n Rapid transport of the trauma patient is essential to improving patient outcome.\n The trauma patient varies in presentation based on the type and mechanism of injury. Primarily, the pre-hospital EMS provider is concerned with five areas in the field; securing the scene to protect both rescuers and patients, conducting a primary assessment and managing any life threats, performing a rapid trauma assessment, extricating the victim rapidly while protecting the cervical spine, and immobilizing and transporting the victim to an appropriate facility while conducting a secondary and ongoing surveys.",
        "scene survey": "As with all scene responses, assessment of the situation begins from the moment of first dispatch. You must not only consider the information received, but take into account the time of day, traffic, weather, safety issues and potential resources that may be required. As you arrive, the first concern should be to assess the scene for safety of responding pre-hospital EMS providers and to develop an index of suspicion for potential injuries based upon the scene and mechanism of injury. Your safety always comes first, followed by your team, then your patient. Once it is determined that the scene is manageable, begin patient triage. There has been some controversy as to which triage method or methods should be used, as there are at least, nine different triage tools available worldwide, including two pediatric versions, but there is little evidence supporting one method over the other. The most common methods found in literature are Simple Triage and Rapid Treatment (START) and JumpSTART (the pediatric version of START), which are both used in North America.",
        "primary assessment": "Once all hazards have been mitigated and you can safely function, you should continue on to the primary assessment to look for any life-threatening injuries. These are injuries and instability of the respiratory and cardiovascular systems that would most likely be fatal within minutes if they are not immediately found and corrected. The approach to the trauma patient is based on the same primary assessment of the patient\u2019s airway, breathing, circulation, neurologic disability, and exposure used for all patients. Unlike a medical patient, the mechanism of injury should also be quickly determined and considered.\nAIRWAY / C-SPINE STABILIZATION / LEVEL OF RESPONSIVENESS:Airway: Patent, maintainable, un-maintainable\nLevel of consciousness, altered mental status\nSkin appearance: Ashen, pale, gray, cyanotic, or mottled\nFacial fractures, head fractures, C-spine step-off\nAirway clearance\nSounds of obstruction\nGlasgow coma scale, AVPU\n\nBREATHING:Once the airway is assessed and managed, a quick assessment of the patient's breathing should be performed. If weather permits, and a chest injury is suspected, exposing the chest is prudent. With a stethoscope in one hand, wrap both hands around the patient's chest high along the mid-axillary line, then repeat on the other side. This allows you to assess for the presence or absence of breath sounds and to feel for equal expansion, crepitus and / or flail segments while visualizing for any injuries. Treatments that may be initiated here include high-flow oxygen, manual ventilations, sealing penetrating chest wounds and decompressing a suspected tension pneumothorax. Summary of Primary -- Breathing Assessment: Rate and depth of respirations, Cyanosis, Position of the trachea, Presence of obvious injury or deformity, Work of breathing, Use of accessory muscles, Flaring of nostrils, Presence of bilateral breath sounds, Asymmetric chest movements, Palpation of crepitus, Integrity of chest wall\n\nBREATHING: Once the airway is assessed and managed, a quick assessment of the patient's breathing should be performed. If weather permits, and a chest injury is suspected, exposing the chest is prudent. With a stethoscope in one hand, wrap both hands around the patient's chest high along the mid-axillary line, then repeat on the other side. This allows you to assess for the presence or absence of breath sounds and to feel for equal expansion, crepitus and / or flail segments while visualizing for any injuries. Treatments that may be initiated here include high-flow oxygen, manual ventilations, sealing penetrating chest wounds and decompressing a suspected tension pneumothorax.\n\nCIRCULATION: Pulse rate and quality, Skin appearance: Color, Peripheral pulses, Skin temperature, Level of consciousness, Open wounds, Arterial and/ or venous hemorrhage",
        "rapid trauma assessment": "A rapid trauma assessment is indicated for any patient whose MOI involves environmental factors (burns, drowning, toxic inhalation, etc), motion, or the transfer of a significant amount of energy to that patient (motor vehicle collisions, projectile penetrations, rapid deceleration, etc). As the primary assessment is meant to look for injuries and conditions that may be fatal in minutes, the rapid trauma assessment looks for injuries or conditions that are more subtle or may not be evident for a longer period (15 - 30 minutes). As others are preparing for the extrication, do a very rapid trauma assessment looking for gross injuries that may pose a problem during extrication, such as multiple long bone or pelvic fractures that may cause pain, further injury and hemorrhage if care is not taken when moving the patient from the vehicle to a backboard. Although this maneuver is \"rapid\" it does not allow for compromise of the cervical spine. Cervical spine injuries should be considered in all trauma patients until they can be ruled out by appropriate medical personnel. A stiff cervical collar, backboard, spider straps, head blocks, and tape, or an appropriate substitution as the need or situation arises, should be used to protect the cervical spine during transport. Neurological assessments of all extremities should be performed and documented before and after all immobilization.\nTo properly perform the rapid trauma assessment, the patient must be fully exposed. Do not feel guilty about cutting away obtrusive clothing if there is a high index of suspicion for injuries based upon the mechanism; however, take into account when and where you expose the patient. If there is a large crowd, maintain the patient's modesty by exposing only what is vital to the assessment and treatment and / or shielding the patient from the crowd with sheets or tarps. Also consider body temperature during exposure, as patients rapidly lose body heat through convection and radiation to the surrounding environment. No matter the temperature outside, always cover the patient with sheets or blankets and consider turning the air-conditioning down, or off, in the ambulance, as cold blood is less likely to clot and trauma patients are more prone to hypothermia.\nIf any serious conditions are found during the rapid trauma assessment, stabilize the patient as soon as possible, but determine to what extent. Look at the patient's overall condition and perform a risk-benefit analysis to determine if the proposed treatment would make a difference in the outcome versus how long it would take to accomplish that treatment considering the patient's other injuries. Also consider whether the desired treatment could be done safely enroute to the intended receiving facility.\nAlways be aware of the time you are spending on scene or on a particular task and be ready to transport if the patient's condition changes. Transport to the closest hospital is always warranted if you are unable to obtain or maintain an airway. Notify the hospital of the airway problem so they can have the appropriate equipment, medications, and personnel in place prior to the patient's arrival.",
        "secondary assessment": "Typically, the secondary assessment begins once any life threats to the patient's airway, breathing, and circulation have been managed and any major injuries are stabilized. In a trauma situation, parts of the secondary assessment may occur simultaneously with other assessments, but should never interfere with them. The ability to do this is directly dependent upon the number of people available and the space within which providers have to work.",
        "vital signs": "When and where you obtain vital signs is directly related to the severity of the patient's condition, the number of responders on the scene, and available access to the patient. Vital signs are commonly left until the patient is in the ambulance and all critical and essential treatment has been established. Occasionally, when there are enough responders, one person may be delegated to obtain vital signs, but remember that this should not delay transport.\nVital sign trending is the practice of continually retaking vital signs to identify changes in patient condition. In the trauma patient, this occurs minimally every five minutes, or whenever the patient's condition changes. Trending will help to determine patient stability and alert providers to impending problems.",
        "ongoing assessment": "The ongoing assessment involves continual reassessment of the patient any time his or her condition changes; an intervention is performed; or after any movement. Regularly reassess the patient's ABCs. Assessing mental status, performing baseline and repeat Glasgow Coma Scale scoring, and checking / rechecking the pupils will help determine any changes in the patient's neurologic status. Constant assessment of neurovascular status will alert you to developing paralysis, shock or a splint that is improperly applied. Subjective information such as asking the patient if s/he is feeling better or worse should be included. And finally, reassessing after interventions is important and may include effectiveness and tightness of splints, patency and flow rates of intravenous lines, and confirmation of endotracheal tube placement.",
        "summary of secondary assessment": "Skin: Presence of petechia, purpura, abrasions, bruises, scars, or birthmarks\nLacerations, uncontrolled hemorrhage\nRashes\nAbnormal skin turgor\nSigns of abuse or neglect\n\nHead and Neck: Presence of lacerations, contusions, raccoon eyes, \nBattle\u2019s sign, or drainage from the nose, mouth, and / or ears\nGross visual examination\nAbnormal extra-ocular movements\nPosition of the trachea\nNeck veins\nSwallowing difficulties\nNuchal rigidity\nPresence of lymphadenopathy or neck masses\nVertebral step-off\n\nEars, Nose, and Throat: Hemorrhage\nDrainage\nSunken eyes\nGross assessment of the hearing\nObstruction\nForeign body\n\nMouth and Throat: Mucous membranes\nDrooling\nBreath odor\nDrainage\nInjuries to teeth\nAirway obstruction\n\nThorax, Lungs, and Cardiovascular System: Breath sounds\nOpen Pneumothorax\nCrepitus\nParadoxical motion\nHeart Sounds\n\nAbdomen: Shape and size\nBowel sounds\nTenderness\nRigidity\nEvisceration\nMasses (i.e. suprapubic masses)\nPelvic tenderness, crepitus, or instability\n\nGenitourinary: Rectal bleeding\nColor of urine\n\nExtremities and Back: Gross motor and sensory function\nPeripheral pulses\nLack of use of an extremity\nDeformity, angulation\nWounds, abrasions\nVertebral column, flank, buttocks\nEquipment is appropriately applied (i.e.traction splints, extremity splints, cervical collar)",
        "assessment acronyms": "S.A.M.P.L.E.:S Signs and Symptoms, A Allergies, M Medications, P Pertinent past medical history, L Last oral intake, E Events leading up to the event\n\nO.P.Q.R.S.T.: O Onset (When did the problem / pain begin?), P Provocation(What makes the problem / pain worse?), Q Quality (Can you describe the problem / pain?), R Radiation (Does the pain move anywhere?), S Severity (On a scale of 1 - 10, how bad is the pain?), T Time (Does the condition come and go? Duration?)\n\nT.I.C.S.: T Tracks, tags, tattoos, I Instability, C Crepitus, S Scars\n\nD.C.A.P. / B.T.L.S.: D Deformities, C Contusions, A Abrasions, P Punctures, B Burns, T Tenderness, L Lacerations, S Swelling"
    },
    {
        "document title": "Adult Trauma Patient Care",
        "protocol title": "Injury \u2013 Conducted Electrical Weapons (i.e. Taser)",
        "overview": "A conducted energy device is a non-lethal, battery-operated device that can deliver  \n50,000 volts of electricity in rapid pulses that st imulate the nerves in the body.  This high-voltage, low -amperage electrical discharge overrides the body\u2019s muscle -triggering \nmechanisms causin g neuromuscular incapacitation.  This neuromuscular incapacitation \noverrides the patient\u2019s sensory and motor nerves of the peripheral nervous system by \ndisrupting the electrical impulses sent by the brain to command skeletal muscle function.",
        "hpi": "\uf0b7 Events leading to incident\n\uf0b7 Drug, ETOH ingestion\n\uf0b7 Medical history (especially cardiac)\n\uf0b7 Medications\n\uf0b7 Last tetanus",
        "signs and symptoms": "\uf0b7 Local injury\n\uf0b7 Altered mental status, unconsciousness\n\uf0b7 Respiratory distress\n\uf0b7 Chest pain\n\uf0b7 Cardiac, respiratory arrest\n\uf0b7 Drug  / ETOH ingestion\n\uf0b7 Cardiac rhythm disturbance\n\uf0b7 Myocardial infarction\n\uf0b7 Respiratory arrest\n\uf0b7 Cardiac arrest",
        "procedure": "1. Perform general patient assessment.\n2. Administer oxygen, to maintain SPO 2 94 - 99%.  Support \nrespirations as necessary with a BVM.\n3. Determine history of events between the time the weapon \nwas  used until EMS arrived.\n4. Per patient assessment (chest pain / palpitations)  place \npatient on cardiac monitor and obtain  / interpret 12 lead  \nECG .  Refer to appropriate Cardiac Care protocol .\n5. Establish IV of Normal Saline at KVO rate, per \nassessment.\n6. If patient is agitated or combative, refer to Behavioral \nEmergencies protocol.\n7. Transport promptly in position of comfort and reassess as \nneeded.",
        "considerations": "The current medical li terature does not support routine  performance of \nlaboratory studies, electrocardiograms, or prolonged ED observation or \nhospitalization for ongoing cardiac monitoring after CEW exposure in an \notherwise asymptomatic, awake and alert patient.",
        "pearls": "1. If deployed by law enforcement, b efore touching any patient tha t has been \nsubdued using a conducted energy device , ensure that the law enforcement \nofficer has disconnected the deployment cartridge from the hand held unit.\n2. If deployed by law enforcement, t he probes and all connecting wires are \nconsidered evidence by law enforcement and should be maintained for \ncollection.\n3. Due to  case reports of  deaths associated with subjects subdued with thes e types \nof devices, all victims  should be transported to the hospital for a thorough \nevaluation.\n4. Encourage l aw enforcement to accompany patient, in ambulance , during \ntransport to receiving facility."
    },
    {
        "document title": "Adult Trauma Patient Care",
        "protocol title": "Exposure \u2013 Airway/Inhalation Irritants",
        "overview": "A majority of fire related deaths are the result of smoke inhalation. Suspect inhalation injury and respiratory damage in any victim of a thermal burn, particularly if the patient has facial burns, singed nasal hair, carbonaceous sputum or was in an enclosed space. Be aware that many chemicals are present during ordinary combustion including Hydrogen Sulfide, Hydrogen Cyanide and Carbon Monoxide (CO). CO is a tasteless, odorless, colorless, and non-irritating gas. Almost any flame or combustion device can produce the gas. CO poisoning is a common problem and produces a broad spectrum of signs and symptoms, often imitating the flu. Think about CO poisoning when multiple patients present with the same signs and symptoms at a residence. Hydrogen cyanide is a by-product of the combustion of materials used in everyday life products (i.e., insulation, carpets, clothing, and synthetics). The culprit is nitrogen. Nitrogen gas in atmospheric air can contribute (under the right circumstances) to the formation of minute amounts of cyanide during combustion. High temperatures and lowoxygen concentrations favor the formation of cyanide gas. Smoke from the combustion of grass clippings, green wood, tobacco, cotton, paper, wool, silk, weeds, and animal carcasses will likely contain some hydrogen cyanide gas. But the real offender is the combustion of manmade plastic and resins containing nitrogen, especially if the fire is hot and in an enclosed space. Common manmade materials that generate cyanide gas during combustion include nylon, polyurethane, melamine, and acrylonitrile.",
        "hpi": "\uf0b7 Type of exposure (heat, gas, chemical)\n\uf0b7 Inhalation injury\n\uf0b7 Time of injury\n\uf0b7 Past medical history\n\uf0b7 Medications\n\uf0b7 Other trauma",
        "signs and symptoms": "\uf0b7 Burns, pain, swelling\n\uf0b7 Dizziness\n\uf0b7 Loss of consciousness\n\uf0b7 Hypotension/ shock\n\uf0b7 Airway compromise, distress\n\uf0b7 Singed facial or nasal hair\n\uf0b7 Hoarseness, wheezing",
        "considerations": "\uf0b7 Electrical\n\uf0b7 Chemical\n\uf0b7 Thermal\n\uf0b7 Radiation",
        "procedure": "1. Perform general patient management. \n2. Support life-threatening problems associated with airway, breathing, and circulation. \n3. Administer oxygen by NRBM or support respirations with a BVM as indicated (SPO2 is often unreliable for these patients).\n4. Consider orotracheal intubation for impending respiratory failure.\n5. Monitor capnography, if available. Maintain a range between 35 - 45 Torr. \n6. Place patient on cardiac monitor and obtain/interpret 12 lead ECG. Refer to appropriate Cardiac Care protocol.\n7. Establish an IV of normal saline at KVO. \n8. If available, consider CPAP with 5 - 10 cm H20 PEEP. \n9. Transport to Burn Center and perform ongoing assessment as indicated.\n10. If carbon monoxide is suspected or confirmed, administer O2 with non-rebreather mask.\n11. If cyanide is suspected or confirmed, and kit is available, administer Cyanokit\u00ae",
        "cyanokit infusion procedure": "Mix and administer Cyanokit\uf0e2 infusion:\n1. Add 200 ml of Normal Saline injection to Hydroxocobalamin 5g vial using supplied transfer spike.\n2. Fill to line on bottle with vial in upright position.\n3. Rock or rotate vial for 60 seconds to mix solution. Do not shake.\n4. Attach included vented IV tubing. Infuse over 15 minutes.\n5. Total amount infused should be documented as 5g.",
        "pearls": "1. Pulse oximetry may give falsely elevated readings in patients with methemoglobin or CO / CN exposure.\n2. Hyperbaric therapy can be indicated for some carbon monoxide poisonings; especially in early pregnancy and patients with failing vital signs. For fire related exposures, transport to the burn center at VCU Health System. For non-fire related CO exposures, contact Medical Control for guidance. Hyperbaric chambers are located at Chippenham Hospital, Southside Regional Medical Center, Retreat Doctor\u2019s Hospital, University of Virginia Medical Center.\n3. Critical burns: burns over > 25% TBSA; 2\uf0b0 burns > 10% TBSA; 2\uf0b0 and 3\uf0b0 burns to the face, eyes, hands, or feet; electrical burns; respiratory burns; deep chemical burns; burns with extremes of age or chronic disease; and burns with associated major traumatic injury. These patients should be transferred directly to a burn center.\n4. Have a high index of suspicion and a low intubation threshold when treating burn patients with possible airway involvement. Early intubation should be considered in significant inhalation injuries.\n5. Burn patients are prone to hypothermia \u2013 never cool burns that involve > 15% TBSA.\n6. Never overlook the possibility of multi-system trauma."
    },
    {
        "document title": "Adult Trauma Emergencies",
        "protocol title": "Injury \u2013 Crush Syndrome",
        "overview": "Crush injuries can result from a variety of mechanisms including mine cave-ins, trench collapses, building collapses, vehicular collisions, or industrial accidents. Also called traumatic rhabdomyolysis, it is defined as the prolonged compression, usually 4 - 6 hours but possibly less than 1 hour, of large muscle mass and compromised local circulation. Crush syndrome may also be exacerbated by hypovolemia secondary to hemorrhage. Compression on the body causes a disruption in tissue perfusion to a muscle group leading to cellular hypoperfusion and hypoxia. Cellular perfusion is further decreased due to hemorrhage from torn or compressed vessels. Once the compressive force is relieved, blood flow resumes, releasing the toxic substances that have been collecting in the compressed areas into the systemic circulation. This can result in systemic metabolic acidosis, widespread vasodilation, and hyperkalemia. Metabolic acidosis and high potassium levels could have deleterious effects on the myocardium and lead to patient death. Cardiac arrest due to hyperkalemia typically occurs within the first hour of removal from compression. Because of this, treatment for crush injuries begins prior to patient removal from compression.",
        "hpi signs symptoms": "\u2022 Entrapment of one or more extremities and/or trunk\n\u2022 Time entrapped\n\u2022 Medical history\n\u2022 Allergies",
        "considerations": "\u2022 Heart Failure\n\u2022 Obvious crushing of a muscle mass (arm, leg, etc.)\n\u2022 Extremity fracture\n\u2022 Paralysis, Spinal cord injury\n\u2022 Compartment syndrome",
        "procedure": "1.  Perform general patient management. (EMR: \u2022, EMT: \u2022, A I P: \u2022 | \u2022)\n2.  Support life-threatening problems. (EMR: \u2022, EMT: \u2022, A I P: \u2022 | \u2022)\n3.  Administer oxygen to maintain a SPO2 between 94 - 99%. Support respirations as necessary with a BVM. (EMR: \u2022, EMT: \u2022, A I P: \u2022 | \u2022)\n4.  Consider activation of local and/or regional technical rescue team. (EMR: \u2022, EMT: \u2022, A I P: \u2022 | \u2022)\n5.  Start an IV of normal saline and administer normal saline 20 cc / kg bolus, prior to extrication if possible. Maintain perfusion by following the Medical \u2013 Hypotension/Shock protocol. DO NOT USE LACTATED RINGERS. (EMR: \u2022, EMT: \u2022, A I P: \u2022)\n6.  Apply and tighten tourniquet on entrapped/crushed extremity BEFORE extrication. (EMR: \u2022, EMT: \u2022, A I P: \u2022)\n7.  Attach ECG monitor. Obtain / interpret 12 Lead ECG. Carefully monitor for dysrhythmias before, immediately after release of pressure and during transport (i.e., peaked T waves, wide QRS, lengthening QT interval, loss of P wave). Contact Medical Control if hyperkalemia is suspected.** (EMR: \u2022, EMT: \u2022, A I P: )\n8.  Transport as soon as possible. (EMR: \u2022, EMT: \u2022, A I P: \u2022)\n9.  For pain control, consider analgesics (EMR: , EMT: \u2022, A I P: \u2022)\n    a. FENTANYL 1 mcg / kg IV / IM, not to exceed 100 mcg single dose. Repeat dose in 10 minutes if necessary. Max total dose is 200 mcg.\n    b. If Fentanyl is unavailable, give MORPHINE 0.1 mg / kg IV at 1 mg / min, not to exceed 5 mg single dose with max total dose of 20 mg. If no IV established, administer MORPHINE 0.1 mg / kg IM, not to exceed 10 mg (1.0 mL); repeat IM dose in 10 minutes if necessary.\n10. Consider the following options:\n    a. Continued boluses of normal saline. (EMR: , EMT: \u2022, A I P: \u2022)\n    b. For 1 limb greater than 2 hours or 2 limbs greater than 1 hour, administer SODIUM BICARBONATE 1 mEq / kg IV bolus over 2 minutes. Consider administration of bicarb containing IV solution (One liter of D 5W with 2 amps bicarb infused at 150 cc / hour). (EMR: , EMT: \u2022, A I P: \u2022)\n    c. If ECG suggestive of hyperkalemia,** consider ALBUTEROL 5.0 mg via small volume nebulizer. (EMR: , EMT: \u2022, A I P: \u2022)\n    d. If ECG suggestive of hyperkalemia, consider CALCIUM CHLORIDE 8 mg / kg of 10% solution IV over 5 minutes. (EMR: , EMT: \u2022, A I P: \u2022)\n11. Transport and perform ongoing assessment as indicated. (EMR: \u2022, EMT: \u2022, A I P: \u2022)",
        "pearls": "1.  A patient with a crush injury may initially present with very few signs and symptoms. A high index of suspicion should be maintained for any patient with a compressive mechanism of injury.\n2.  Elevated potassium levels have an increased risk of affecting the myocardium resulting in ventricular tachycardia and ventricular fibrillation.\n3.  Suspect hyperkalemia if T-waves become peaked, QRS becomes prolonged (>0.12 seconds), absent P wave, or prolonged QTc**.\n4.  If a possible field amputation is anticipated, contact Medical Control for guidance.\n5.  Sodium Bicarbonate will keep the urine alkalotic and assist in preventing acute renal failure.\n6.  Tourniquets should be applied above the crush.",
        "suggestive signs hyperkalemia": "\u2022 Peaked T waves in V1 and V2\n\u2022 Widened QRS (> 0.12 seconds)\n\u2022 QTc > 500\nIf any of these findings are noted on a 12 lead: Contact Medical Control"
    },
    {
        "document title": "Adult Trauma Patient Care",
        "protocol title": "Injury \u2013 Spinal Motion Restriction",
        "overview:": "Mechanism of injury alone has not been shown to be a predictor for spinal injury. An appropriate patient assessment can be used to determine need for spinal motion restriction. The below is cervical spinal motion restriction selection guidelines taken from National Model Guidelines V2 and NEXUS (National Emergency X - Radiography Utilization Study).\nThere is limited data studying spinal motion in patients with applied cervical collars. Patient exiting out of car under their own power, with cervical collar in place, may result in the least amount of motion of the cervical spine.i Cervical spinal motion restriction devices include, but are not limited to soft and hard collars.\nLong back boards have not been shown to reduce spinal injury complications. Long backboards are associated with increased pain, decubitus development, and possibly decreased functional residual capacity of the lungs. Long backboards and scoop stretchers may be used for the safe movement/transfer of patients. However, if used in this way, patients should be removed from the device as soon as possible.",
        "hpi": "* Time of injury\n* Mechanism of injury (blunt vs. penetrating)\n* Restraints/protective devices\n* Prior cervical spine surgery\n* Known vertebral disease\n* Medical history\n* Medications\n* Evidence of multi-system trauma",
        "signs and symptoms": "* Spine pain\n* Limited neck mobility\n* Neurological deficit\n* Unstable/abnormal vital signs",
        "considerations": "* Spinal cord injury\n* Fracture of vertebrae\n* Head injury\n* Neurogenic shock\n* Distracting injury (long bone injury, deformity, non-life threatening bleeding)",
        "procedure": "1. Maintain scene and provider safety.\n2. Perform general patient management.\n3. Support life-threatening problems.\n4. Spinal motion restriction is not recommended in patients with penetrating trauma.\n5. Cervical spinal motion restriction should be used in patients meeting the below criteria.\n    a. Patients between 15 and 65 years of age with a traumatic mechanism and any one (1) of the following:\n        - Midline cervical tenderness\n        - Neuro deficits\n        - Altered mental status\n        - Intoxication\n        - Distracting injury\n    b. Patients 65 years of age and older with traumatic mechanism and suspected spinal injury should have cervical spinal motion restriction.\n    c. Any patient where provider judgement indicates use of SMR (i.e., seatbelted in cot, backboard, reeves).\n6. Backboards may be used for movement or extrication of the patient. Patients should be removed from the backboard as soon as possible.\n7. Transport to an appropriate facility as indicated by the Regional Field Triage Scheme if applicable, and perform ongoing assessment as indicated.",
        "pearls:": "* EMS Providers are expected to use good judgment and may elect to apply cervical spinal motion restriction device to any patient.\n* Mechanism of injury alone has not been shown to be a predictor for spinal injury. All patients with a dangerous mechanism of injury, AMS, spine tenderness, distracting injuries, or an unreliable physical exam should be treated in such a manner as to limit spinal motion."
    },
    {
        "document title": "Adult Trauma Patient Care",
        "protocol title": "Injury \u2013 Sexual Assault",
        "overview": "A patient that has experienced the trauma of sexual abuse may present in a variety of ways. Physical trauma may be evident along with emotional trauma, which is very prevalent in these situations. In other cases, emotional trauma may be the only presenting problem. Pre-hospital EMS providers may be thrust into the role of mediator, buffer, or confidant. They may even be subject to violent aggression on the part of the victims or their families. Injuries associated with sexual assault may vary widely. They can be as subtle as slight pain or discomfort or as grossly evident as either debilitating or disfiguring trauma. The victim\u2019s injuries also may not be obvious or visible on first inspection; some may even deny injuries and relay untruthful information regarding the occurrence. The pre-hospital provider must develop and foster rapport with the victim to gain the victim\u2019s confidence, so that accurate information can be obtained.",
        "hpi": "Type of injury\n Mechanism: rape, sodomy, sexual abuse\n Timeline of incidents\n Medical history\n Medications",
        "signs and symptoms": "Physical injuries\n Emotional injuries\n Recurring injuries\n Withdrawal, hostility",
        "considerations": "Emotional trauma\n Behavioral disorder\n Traumatic injury",
        "procedures": "1. Obtain general patient assessment.    \n2. Support life-threatening problems associated with airway, breathing, and circulation.    \n3. Assess for signs of trauma; take C-spine precautions per assessment.    \n4. Administer Oxygen to maintain SPO2 94-99%    \n5. Perform wound care only to assess the severity and provide hemorrhage control.    \n6. If an acute medical condition is noted, refer to appropriate Medical Patient protocol.    \n7. If physical trauma is noted, refer to appropriate Trauma Patient protocol.    \n8. Discourage the patient from changing clothes or bathing.    \n9. Transport promptly in position of comfort to appropriate facility. Reassess as needed.",
        "pearls": "1. Use paper bags for all clothing and blood-stained articles, if available. If the patient\u2019s clothing is removed after leaving the scene, bag and label each item separately.\n2. Do not ask questions about the patient\u2019s sexual history or practices, or questions that might make the patient feel guilty.\n3. Do not examine the patient\u2019s genitalia unless there is severe injury, and then do so only with the patient\u2019s permission.\n4. Maintain the crime scene and chain of evidence by turning over any transported items to forensic nursing staff at receiving facility, if available.\n5. The receiving facility should be contacted prior to transport to notify of patient complaint and ascertain if forensic nursing (Sexual Assault Nurse Examiner - SANE) is available. EMS may be diverted due to lack of forensic capabilities."
    },
    {
        "document title": "Pediatric Trauma Patient Care",
        "protocol title": "Pediatric Traumatic Arrest",
        "overview": "Survival from traumatic cardiac arrest is poor. Ideally, patients in traumatic arrests are managed in the field until ROSC or termination of efforts.",
        "transport decisions": "Distance from the level 1 or 2 trauma center may influence transport decisions. Transport times greater than 15 minutes to the trauma center should be managed in the field unless extenuating circumstances exist.",
        "pearls": "* Consider anterior mid-axillary placement for larger adults when using 14-gauge IV catheters.\n* Penetrating traumatic cardiac arrest generally has better outcomes than blunt traumatic arrest.\n* ACLS drugs may impair tissue perfusion in hemorrhagic shock and should be limited to a single early dose if used.\n* Focus on managing external hemorrhaging, airway, needle decompression, chest compressions, and defibrillation as appropriate.\n* Priority of transport destination:\n    * Level 1 Trauma Center\n    * Level 2 Trauma Center\n    * Level 3 Trauma Center\n    * Closest Appropriate Facility\n* Consider scene safety and security when making transport decisions."
    },
    {
        "document title": "Pediatric Trauma Emergencies",
        "protocol title": "Injury \u2013 Burns \u2013 Thermal",
        "overview": "Burns are a devastating form of trauma associated with high mortality rates, lengthy rehabilitation, cosmetic disfigurement, and permanent physical disabilities. Thermal, chemical, electrical, (nuclear) radiation or solar sources may cause burns. Burns can affect more than just the skin. Burns are classified by degree, 1 \uf0b0 (superficial) some reddening to skin, 2 \uf0b0 (partial thickness) has blistering and deep reddening to the skin, and 3\uf0b0 (full thickness) causes damage to all skin layers and is either charred / black or white / leathery with little or no pain at the site. The patient\u2019s palm equals 1% of body surface area when determining the area affected. Scald injuries are more common in younger children while flame injuries are more common in older children and account for the most fatalities. Smoke inhalation is the most common cause of death in the first hour after a burn injury. Children who have burn injuries are at a greater risk than adults for shock and hypothermia because of their proportionately large body surface.",
        "hpi": "* Type of exposure (heat, gas, chemical)\n* Time of injury\n* Past medical history\n* Medications\n* Other trauma",
        "signs and symptoms": "* Inhalation injury\n* Burns, pain, swelling\n* Dizziness\n* Loss of consciousness\n* Hypotension/ shock\n* Airway compromise, distress\n* Singed facial or nasal hair\n* Hoarseness, wheezing\n* Superficial (1 \uf0b0), red and painful\n* Partial thickness (2 \uf0b0), blistering\n* Full thickness (3 \uf0b0), painless and charred leathery skin",
        "considerations": "* Chemical, Thermal, Radiation",
        "procedure": "1. Stop the burning process:\n   a. Thermal burns: Lavage the burned area with sterile water or saline to cool skin. Do not attempt to wipe off semisolids (grease, tar, wax, etc.) Do not apply ice. Dry the body when the burn area is greater than or equal to 10% TBSA to prevent hypothermia.\n   b. Dry chemical burns: Brush off dry powder, then lavage with copious amounts of tepid water (sterile, if possible) for 20 minutes. Continue en route to the hospital.\n   c. Liquid chemical burns: Lavage the burned area with copious amounts of tepid water (sterile, if possible) for 20 minutes. Continue en route to the hospital.\n2. Support life-threatening problems.\n3. Perform general patient management.\n4. Administer oxygen, via non-rebreather mask, at 10 - 15 L / min. as necessary. Use humidified oxygen if suspected inhalation injury and when available.\n5. If the patient is in critical respiratory distress, consider early placement of an advanced airway.\n   *Endotracheal Intubation / cricothyrotomy are reserved as Paramedic only.*\n6. Remove clothing from around burned area, but do not remove/peel off skin or tissue. Remove and secure all jewelry and tight fitting clothing.\n7. Assess the extent of the burn using the rule of nines and the degree of burn severity.\n8. Cover the burned area with a clean, dry dressing. Wet dressing may be used if the burned TBSA is less than 10%.\n9. If a partial or full thickness burn involves more than 20% TBSA, establish an IV of NS or LR (if available). Infuse the fluid amounts listed as below. If the patient develops signs and symptoms of fluid overload respiratory distress (dyspnea, crackles, rhonchi, decreasing SpO2), slow the IV to KVO.\n   a. For patients 5 years and younger, start at 125mL/hr.\n   b. For patients 6 -13 years, start at 250mL/hr.\n   c. For patients 14 years and older, start rate at 500 mL/hr.\n10. For pain control, refer to the Pediatric Pain Management protocol.\n11. Perform ongoing assessment as indicated and transport major burns to Level 1 Burn Center. Transport minor burns to appropriate facility.",
        "management notes": "Excessive fluid resuscitation can lead to compartment syndromes.\n**Normal Saline or Lactated Ringers are fluids of choice in burn patients**",
        "pearls": "1. Remove patient\u2019s clothing as appropriate. Remove rings, bracelets and other constricting items in areas of burn, if possible.\n2. Critical burns: burns over > 25% TBSA, 2\uf0b0 burns > 10% TBSA, 2\uf0b0 and 3\uf0b0 burns to the face, eyes, hands, or feet, electrical burns, respiratory burns, deep chemical burns, burns with extremes of age or chronic disease, and burns with associated major traumatic injury. These patients should be transported directly to a VCU Pediatric Emergency department, if possible.\n3. Have a high index of suspicion and a low intubation threshold when treating burn patients with possible airway involvement. Early intubation is recommended in significant inhalation injuries.\n4. Circumferential burns to extremities are dangerous due to potential vascular compromise secondary to soft tissue swelling.\n5. Burn patients are prone to hypothermia \u2013 never cool burns that involve > 15% TBSA.\n6. Never overlook the possibility of multi-system trauma.\n7. Burns are extremely painful. Strongly consider pain management medications as needed.\n8. Assess for potential child abuse and follow appropriate reporting mechanism as needed.\n9. Keep the child warm and protect from hypothermia. Be cautious with cool dressings."
    },
    {
        "document title": "Pediatric Trauma Patient Care",
        "protocol title": "General \u2013 Neglect or Abuse Suspected",
        "overview": "Child r abuse, which includes sexual abuse, physical abuse, and neglect, is often overlooked and under-reported. It is the ethical and legal responsibility to notify the receiving hospital of suspicions of child abuse as it may prevent serious injury and death. Proof of abuse is not needed to make the report to hospital, CPS, or social services. Patterns of abuse can reflect any form of physical and/or mental trauma, but are usually characterized by unexplained or poorly explained injuries of different ages and delay in seeking medical care. There may be sometimes be no external signs of injuries. Observation, transport, and reporting are the key responsibilities of the prehospital provider.",
        "hpi": "Time of injury \nMechanism: blunt vs penetrating\nLoss of consciousness\nBleeding\nPast medical history\nMedications\nEvidence of multisystem trauma",
        "signs and symptoms": "Pain, swelling, bleeding\nAltered mental status, unconsciousness\nRespiratory distress, failure\nDehydration\nFractures\nDecubitus\nMajor traumatic mechanism of injury",
        "considerations": "Skull fracture\nBrain injury(concussion, contusion, hemorrhage, or laceration\nEpidural hematoma\nSubdural hematoma\nSubarachnoid hemorrhage\nSpinal injury",
        "procedure": "1. Perform general patient management.\n2. Support life-threatening problems; C-spine precautions.\n3. Administer oxygen, to maintain SPO2 94 - 99%. Support respirations as necessary with a BVM.\n4. Observe and record objectively the surroundings and conditions of the scene and patient.\n5. Refer to the appropriate Medical or Trauma Patient Care protocol for obvious injuries / illnesses.\n6. UNDER VIRGINIA LAW, EMS PROVIDERS ARE MANDATORY REPORTERS OF SUSPECTED CHILD ABUSE. (VA code 63.2-1509) Report suspicions to the receiving facility emergency department attending physician on arrival, or report suspicions immediately to Child Protective Services. CPS Hotline: 800-552-7096.\n7. Transport as soon as possible."
    },
    {
        "document title": "Pediatric Trauma Emergencies",
        "protocol title": "Injury \u2013 Abdomen (Abdominal Trauma)",
        "overview": "Blunt and penetrating trauma are major causes of morbidity and mortality in the United States. Pediatric abdominal anatomy differs from adults in several unique ways. There is significantly less protection due to thinner muscle walls and less fat. Ribs protecting the thoracic abdomen have increased flexibility more easily allowing the ribs to injure the abdominal organs. Solid organs within the pediatric abdomen have a larger surface area thus a greater area is exposed for potential injury. The organ attachments are also more elastic, increasing the chances of tearing and shearing injuries. Lastly, the bladder extends to the umbilicus in the pediatric patient, increasing its chance for injury. When performing a focused abdominal assessment, be organized, efficient, and thorough. Initial abdominal examinations only identify injury about 65% of the time; secondary exams are needed when there is a high index of suspicion for abdominal trauma. A proper abdominal examination involves exposing the entire abdomen from the nipple line to the groin and using a standard examination sequence of inspection, auscultation, percussion, and palpation.",
        "hpi": "* Time of injury\n* Mechanism: blunt vs penetrating\n* Loss of consciousness\n* Damage to structure, vehicle\n* Location in structure or vehicle\n* Speed, details of MVC\n* Restraints, protective devices\n* Medical history\n* Medications\n* Evidence of multi-system trauma",
        "signs and symptoms": "* Pain, swelling, bleeding\n* Deformity, lesions\n* Altered mental status, unconsciousness\n* Respiratory distress, failure\n* Hypotension, shock\n* Arrest\n* Significant mechanism of injury",
        "procedure": "1. Maintain scene and provider safety.\n2. Perform general patient management.\n3. Administer supplemental oxygen to maintain SpO2 94-99%. If need to assist ventilations with BVM, maintain C-spine precautions.\n4. Identify mechanism of injury.\n5. Establish large bore IV\u2019s of normal saline. Titrate to an appropriate systolic blood pressure:\n    a. Birth to 1 month - 60 mmHg\n    b. 1 month to 1 year -  > 70 mmHg\n    c. Greater than 1 year - 70 + [2 x Age (years)]\n6. Treat pain if indicated. Refer to Pediatric Pain Management protocol.\n7. Consider ONDANSETRON (ZOFRAN)  0.1mg / kg slow IVP over 2 \u2013 5 minutes, max 4.0 mg per dose as needed per Pediatric Nausea and vomiting protocol.\n8. Transport to the appropriate hospital per Trauma Triage Scheme and reassess as indicated.",
        "considerations": "Impaled Objects:\nStabilize impaled objects in place with bulky dressings.\n\nSevere Hemorrhage from Open Penetrating Injury:\nControl bleeding with well-aimed direct pressure directly on the bleeding source.  Once controlled apply dry, sterile dressing.\n\nEvisceration with Protruding Abdominal Contents:\nLoosely wrap any protruding abdominal contents with a sterile dressing moistened with Normal Saline and cover in entirety with an occlusive dressing over top.",
        "pearls": "1. The amount of external bleeding is not an indicator of the potential severity of internal bleeding associated with an underlying trauma.\n2. Abdominal eviscerations are a surgical emergency. The protruding organ requires careful cleaning and evaluation prior to reinsertion. Do not attempt to reinsert the organs in  the pre-hospital setting.\n3. Impaled objects in the abdomen often tamponade internal hemorrhage, and removing them may trigger significant internal bleeding. Remember that any bump against the object moves the distal end in the organ and worsens damage."
    },
    {
        "document title": "Pediatric Trauma Patient Care",
        "protocol title": "PROTOCOL TITLE: General \u2013 Pediatric SMR",
        "overview": "Mechanism of injury alone has not been shown to be a predictor for spinal injury. An appropriate patient assessment can be used to determine the need for spinal motion restriction. The below are cervical spinal motion restriction selection guidelines taken from National Model Guidelines V2 and NEXUS (National Emergency X-Radiography Utilization Study).\nThere is limited data studying spinal motion in patients with applied cervical collars. Patients exiting a car under their own power, with cervical collar in place, may result in the least amount of motion of the cervical spine. Cervical spinal motion restriction devices include, but are not limited to, soft and hard collars.\nLong backboards have not been shown to reduce spinal injury complications. Long backboards are associated with increased pain, decubitus development, and possibly decreased functional residual capacity of the lungs. Long backboards and scoop stretchers may be used for the safe movement/transfer of patients. However, if used in this way, patients should be removed from the device as soon as possible.",
        "hpi considerations": "* Time of injury\n* Mechanism of injury (blunt vs. penetrating)\n* Restraints/protective devices\n* Prior cervical spine surgery\n* Known vertebral disease\n* Medical history\n* Medications\n* Evidence of multi-system trauma",
        "signs and symptoms": "* Spine pain\n* Limited neck mobility\n* Neurological deficit\n* Unstable/abnormal vital signs\n* Spinal cord injury\n* Fracture of vertebrae\n* Head injury\n* Neurogenic shock\n* Distracting injury",
        "procedure": "1. Maintain scene and provider safety.\n2. Perform general patient management.\n3. Support life-threatening problems.\n4. Spinal motion restriction is not recommended in patients with penetrating trauma.\n5. Cervical spinal motion restriction should be used in patients meeting the below criteria.\n    a. Patients 14 years of age and younger with a traumatic mechanism and any one of the following criteria:\n        - Torticollis\n        - Substantial Injury\n        - High-risk MVC\n        - Diving Incidents\n        - Neurological Deficits\n        - Altered Mental Status\n        - Intoxication\n    c. Any patient where provider judgment indicates the use of SMR (backboard, strapped to stretcher, Reeves, etc.)\n6. Backboards may be used for movement or extrication of the patient. Patients should be removed from the backboard as soon as possible.\n7. Transport to an appropriate facility as indicated by the Regional Field Triage Scheme if applicable, and perform ongoing assessment as indicated."
    },
    {
        "document title": "Pediatric Trauma Emergencies",
        "protocol title": "Injury \u2013 Electrical Injuries",
        "overview": "The vast majority of electrical injuries are caused by generated electricity, such as that encountered in power lines and household outlets. Relative to the external damage caused by electrical injuries, internal damage is often more severe, and can include damage to muscles, blood vessels, organs, and nerves. Damaged muscle releases myoglobin and potassium, which can precipitate in the kidneys and cause acute renal failure. Electrical current as low as 20 mA can cause respiratory arrest and as little as 50 mA can cause ventricular fibrillation. Although long-bone fractures and spinal injuries can occur due to falls after electrocution, they can additionally occur due to severe tetanic muscle spasms with high amplitude electrocutions. Before treating any patient with an electrical injury, ensure your personal safety. Do not touch the patient, if the patient is still in contact with the electrical source.",
        "hpi": "* Lightning or electrical exposure\n* Single or multiple victims\n* Trauma secondary to fall from high wire or MVC into line\n* Duration of exposure\n* Voltage and current (AC / DC)",
        "signs and symptoms": "* Burns\n* Pain\n* Entry and exit wounds\n* Hypotension and shock\n* Cardiac and / or respiratory arrest",
        "considerations": "Cardiac arrest\nRespiratory arrest\nSeizure\nBurns\nMultisystem trauma",
        "procedure": "1. Perform general patient management.\n2. Support life-threatening problems.\n3. Administer oxygen to maintain SPO2 94 - 99%. Consider supporting respirations with a BVM.\n4. Determine extent of any burn injuries. Refer to the Pediatric Burns protocol. Avoid initiating IVs in areas of burn unless absolutely necessary.\n5. Place patient on cardiac monitor; obtain / interpret 12 Lead ECG. Refer to the appropriate Pediatric Cardiac Care protocol for dysrhythmias.\n6. Establish an IV of normal saline to titrate an appropriate BP:\n   a. Birth to 1 month -> 60 mmHg\n   b. 1 month to 1 year -> 70 mmHg\n   c. Greater than 1 year - 70 + [2 x Age (years)]\n7. Consider administration of pain management per Pediatric Pain Management protocol.\n8. Transport to an appropriate facility and perform ongoing assessment as indicated.",
        "pearls": "1. Ventricular fibrillation and asystole are the common presenting dysrhythmias associated with electrical injuries.\n2. Injuries are often hidden. The most severe injuries will occur internally in the muscles, vessels, organs, and nerves.\n3. Do not overlook other trauma (i.e ., falls).\n4. Lightning is a massive DC shock most often leading to asystole as a dysrhythmia.\n5. In lightning injuries, most of the current will travel over the body surface producing flash burns over the body that appears as freckles."
    },
    {
        "document title": "Pediatric Trauma Emergencies",
        "protocol title": "Injury \u2013 Head Injury",
        "overview": "Brain injury and its accompanying pathologic processes continue to be the leading cause of mortality associated with trauma. Whether the injury is due to a blunt or penetrating mechanism, bleeding or swelling of the brain and surrounding tissue may lead to an increase in pressure within the cranial cavity, otherwise known as intracranial pressure, (ICP). If pressure within the skull is not controlled, neurologic changes may produce signs and symptoms ranging from headache to coma with loss of protective reflexes. Blunt force trauma may result in scalp injury, skull fracture, and meningeal and brain tissue injury. Penetrating trauma may produce focal or diffuse injury, depending on the velocity of the penetrating object. Although the pre-hospital provider cannot reverse the brain tissue damage from the initial/primary brain injury that has already occurred, they can play a major role in preventing or limiting the processes that exacerbate and lead to a secondary brain injury. The pre-hospital provider\u2019s goal is to focus on reversing any hypoxia, hypotension, hypercarbia, acidosis, or increasing intracranial pressure.",
        "hpi signs and symptoms": "- Time of injury\n- Mechanism: blunt vs penetrating\n- Loss of consciousness\n- Bleeding\n- Past medical history\n- Medications\n- Evidence of multi-system trauma\n- Pain, swelling, bleeding\n- Altered mental status, unconsciousness\n- Respiratory distress, failure\n- Vomiting\n- Seizure",
        "considerations": "- Major traumatic mechanism of injury\n- Skull fracture\n- Brain injury (concussion, contusion, hemorrhage, or laceration)\n- Epidural hematoma\n- Subdural hematoma\n- Subarachnoid hemorrhage\n- Spinal injury\n- Abuse",
        "procedure": "1. Perform general patient management and baseline GCS.\n2. Support life-threatening problems associated with airway, breathing, and circulation. Obtain mechanism or injury.\n3. Administer oxygen to maintain SpO2 94 - 99%. Consider supporting respirations with a BVM. If signs of hypoventilation are present, ventilate with BVM at an age appropriate rate.\n4. Monitor capnography if BVM or intubated/alternative airway. Attempt to maintain between 35 - 45 mm Hg.\n5. Consider spinal precautions based on MOI. Avoid excessive compression around the neck by cervical collar. Assess and document PMS in all extremities before and after movement.\n6. Place patient on cardiac monitor.\n7. Establish an IV of normal saline, if indicated, to maintain an appropriate systolic BP:\n   a. Birth to 1 month \u2013 60 mmHg\n   b. 1 month to 1 year \u2013 > 70 mmHg\n   c. Greater than 1 year - 70 + [2 x Age (years)]\n8. Obtain a blood glucose sample.\n9. If patient is exhibiting signs of shock, refer to Pediatric Shock protocol.\n10. Transport per Trauma Triage Scheme and perform ongoing assessment as indicated.",
        "pearls": "1. Hyperventilation is not recommended with head-injury patients.\n2. One of the most important indicators of worsening head injury is a change in LOC and/or GCS.\n3. Increased ICP may cause hypertension and bradycardia (Cushing\u2019s response).\n4. Hypotension usually indicates injury or shock unrelated to the head injury and should be treated aggressively.\n5. A decrease of two (2) or more in the patient\u2019s GCS should be considered due to a severe head injury until proven otherwise.\n6. Recognize that \u201cnormal\u201d blood pressure is not as important as \u201cnormal for the patient\u201d when assessing maintenance of adequate cerebral blood flow and adequate cerebral perfusion.",
        "glasgow coma scale modified for pediatric patients": "Eye Opening Response (<1 year)\nSpontaneous: 4\nTo shout: 3\nTo pain: 2\nNone: 1\n\nVerbal Response (0 to 2 years)\nBabbles, coos appropriately: 5\nCries but inconsolably: 4\nPersistent crying or screaming in pain: 3\nGrunts or moans to pain: 2\nNone: 1\n\nMotor Response (<1 year)\nSpontaneous: 6\nLocalizes pain: 5\nWithdraws to pain: 4\nAbnormal flexion to pain (decerebrate): 3\nAbnormal extension to pain (decordicate): 2\nNone: 1"
    }
]