Skills Station: Trauma Care

When responding to a "trauma" incident, it is important for prehospital care providers to be able to quickly determine the potential mechanism of injury, or "MOI." Trauma is either blunt or penetrating in nature. Providers must also be able to suspect or anticipate the potential injuries that may result from the MOI, which can provide insight regarding the patient's overall condition and may guide prehospital treatment.

Blunt Trauma

Depending on the MOI and the injury(s) sustained, the presence of blunt trauma, such as open wounds, external hemorrhage and grossly deformed anatomy, may be obvious. Less obvious findings like crepitus or abdominal distention that are noted during the patient assessment require close attention to assessment findings.

Blunt Trauma Factors

In blunt trauma MOI, several factors must be considered. For example: In a motor vehicle collision, is the steering wheel bent? Is the steering column intact? Is there patient compartment intrusion? Was a seat belt worn? Were the airbags deployed? Is the windshield intact? Were any of the vehicle's occupants ejected (or voluntarily jumped) from the vehicle? Was an occupant of the vehicle a fatality?

In a motorcycle accident, was the operator wearing a helmet? Was the operator thrown from the motorcycle? Did the operator have to "lay the bike down"? How many people were riding on the motorcycle at the time of the accident?

Falls and assaults are additional examples of blunt trauma. In a fall, were there any contributing factors? Was the patient climbing a ladder that came in contact with power lines, leading to electrocution and a fall with subsequent blunt trauma injuries? Was the patient climbing a rock wall and fell? Was the patient attempting to commit suicide by jumping from the roof of a parking garage or building? If an assault, was a weapon used? If so, what type? A brick, baseball bat, furniture, tire iron or a bottle? Based on the assault and the weapon, what types of injuries are possible?

Penetrating Trauma

Penetrating trauma has different characteristics than blunt trauma. For example, the presence of an open wound on the patient's skin does not necessarily reflect the extent of internal damage. Internal injuries due to a stabbing mechanism may vary considerably in comparison to the internal injuries sustained as a result of a projectile (e.g., gunshot). In a stabbing, the internal damage may be limited to the immediate anatomy that was contacted by the object used for stabbing. In a gunshot wound scenario, the bullet (e.g. projectile) may have traveled throughout the patient's body and a variety of injuries may have been sustained.

Location

Penetrating wounds that are located mid-thigh or higher (e.g. pelvis, abdomen, chest, axilla, neck or head) should be considered to be potentially life-threatening until proven otherwise. The reason for this is that there are anatomical structures, such as blood vessels and organs, in these areas that can create a potentially critical condition for the patient if they are traumatized. Internal injuries from penetrating trauma may present without obvious external signs and symptoms. Internal hemorrhage, organ content leakage and bone fractures are possible. From the outside, the patient may appear to be stable; internally, he may be critically wounded.

One Wound

The presence of a single penetrating wound, especially in the case of a suspected shooting, should raise your suspicion. When possible, the patient should be thoroughly evaluated for the presence of a second wound. For example, if an "entrance" wound is located, look for an "exit" wound. If an exit wound (or second wound) is not located, suspect that the bullet is somewhere in the patient's body. Because it is not possible to trace the bullet within the body, assume that the patient has sustained serious injuries until proven otherwise.

Airway Management

The need for airway management in trauma cases varies. Factors influencing this include the patient's injuries, provider training, local protocols and proximity to an emergency department. Prior to initiating airway management procedures, ensure that key equipment and resources are available. This includes oxygen, suction and basic airway devices, such as a bag-valve-mask and oropharyngeal (oral) airways.

Immobilization

There is extensive information in medical literature regarding the use of immobilization in the prehospital setting. For the purposes of this discussion, "immobilization" refers to the use of a cervical collar and long backboard (or other similar device) with the goal of minimizing excessive patient movement. Refer to your local guidelines and/or protocols regarding the use of immobilization in blunt and penetrating trauma cases. Intravenous Access

There are numerous situations in blunt or penetrating trauma in which intravenous access may be indicated. The location and method of obtaining intravenous access varies greatly among EMS systems. For example, a traditional catheter-over-needle system may be inserted in the area of the patient's antecubital fossa, or "AC." Some providers may prefer using a vein along the patient's forearm, hand or external jugular vein. Other examples include femoral venous catheterization, as well as intraosseous infusions.

Fluid Selection and Administration

There are several options to consider regarding intravenous fluid selection in the prehospital setting. Fluid selection and rate of administration should be guided by local protocols, the patient's potential injuries and provider judgment. Common fluid options include crystalloids and colloids. Blood substitutes and hypertonic crystalloid solutions may also be used in either blunt or penetrating trauma, depending on the EMS system.

Summary

Trauma scenarios involve numerous MOI factors that prehospital care providers must remain aware of. Failing to recognize either form of trauma can have devastating consequences on the patient's outcome. The provider who is able to successfully determine the MOI and anticipate the patient's potential injuries will have greater success forming a possible treatment plan, which can contribute to better patient outcomes.

Paul Murphy, MSHA, MA, has administrative and clinical experience in healthcare organizations.