International Trauma

Life Support
for Prehospital Care Providers
Sixth Edition
Patricia M. Hicks, MS, NREMTP
Roy Alson, PhD, MD, FACEP
Donna Hastings, EMT-P
John Emory Campbell, MD, FACEP
and Alabama Chapter,
American College of Emergency Physicians

Chapter 1
Scene Size-up
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ

Scene Size-up

Courtesy of Bonnie Meneely, EMT-P

Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ

Overview
Relationship of time to patient survival
Actions on scene

Steps of Scene Size-up

Two basic mechanisms of motion injury
Mechanisms and settings

Two most common forms of penetrating injury

Mechanisms and extent

Assessment criteria for falls

Anticipated injuries
Scene Size-up - 3
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ

Overview
Blast injury factors related to assessment
Collisions in motor-vehicle crash

Potential injuries related to vehicle damage

Common motor-vehicle crash forms

Lateral-impact compared to head-on collision

Potential head-on collision injuries
Proper and improper use of safety devices

Potential rear-end collision injuries

Higher mortality rate for ejection
Scene Size-up - 4
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ

Trauma

For severely injured patients,

survival is time-dependent!

Scene Size-up - 5
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ

Trauma Survival
Golden Hour
From moment of injury
To definitive treatment

EMS platinum 10 minutes

Assessment and management
Every action must have lifesaving purpose
Organized, detail-oriented, selective, rapid
Scene Size-up - 6
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ

Trauma Care
Teamwork is important!
You must know:
What you can handle and what you cant
What you should handle and what you shouldnt
When to stay and when to leave
Fastest route there and fastest route away
What to do, what not to do, and when to wait
Scene Size-up - 7
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ

Scene Size-up
A critical part of trauma assessment
Anticipate what you will find at scene
Anticipate equipment and resource needs
Form a plan of approach
Be prepared to modify that plan

Failure to size-up can jeopardize lives.

Scene Size-up - 8
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ

Scene Size-up
First step in ITLS Primary Survey

Scene Size-up - 9
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ

Scene Size-up
1. Standard precautions
2. Scene safety
3. Initial triage (total number of patients)
4. Need for more help or equipment
5. Mechanism of injury

Scene Size-up - 10
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ

Standard Precautions

Personal protective equipment is

always needed at trauma scenes.

Scene Size-up - 11
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ

Scene Safety
Ambulance positioning
Safe place to park
Facing away from scene

Windshield survey
Threats to you
Threats to/from patient
Threats to/from bystanders

Courtesy of Bonnie Meneely, EMT-P

Scene Size-up - 12
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ

Initial Triage
Total number of patients
Call for backup
Medical command
Initiate MCI protocols
Any more patients?
Courtesy of Bonnie Meneely, EMT-P

Scene Size-up - 13
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ

Need for More

Essential equipment
Carry to scene for time efficiency
Change gloves between patients

Additional resources
Call early
Relay what to expect, where to respond

Scene Size-up - 14
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ

Mechanism of Injury
Energy follows physics laws.
Injuries present in predictable patterns

High-energy at risk for severe injury.

Consider injured until proven otherwise

Factors to consider:
Direction and speed of impact, patient kinetics
and physical size, signs of energy release
Scene Size-up - 15
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ

Basic Motion Mechanisms

Blunt injuries

Penetrating injuries

Rapid forward
deceleration

Projectiles

Rapid vertical
deceleration

Knives
Falls upon objects

Blunt instrument
energy transfer

Scene Size-up - 16
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ

Motor-Vehicle Collisions
Each collision is three collisions:

Machine
Collision

Body
Collision

Organ
Collision

Scene Size-up - 17
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ

Other Collisions
Secondary collisions
Objects are missiles
at original speed

Additional impacts
Vehicle collides
with another object
Other vehicles collide
with original vehicle
Scene Size-up - 18
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ

Clues to Injury
Deformity of vehicle
What forces were involved in collision?

Deformity of interior structures

What did patient hit?

Deformity or injury patterns on patient

What anatomic areas were hit?

Scene Size-up - 19
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ

Common Collisions
Common types
Head-on
Lateral-impact (T-bone)
Rear-impact
Rollover
Rotational

Scene Size-up - 20
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ

Head-on Collision
Windshield injuries
Brain, soft-tissue injury, cervical
spine

Steering wheel injuries

Traumatic tattooing of skin

Dashboard injuries

Courtesy of Bonnie Meneely, EMT-P

Face, brain, cervical spine,

pelvis, hip, knee
Scene Size-up - 21
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ

Lateral-Impact Collision
Similar to head-on
with lateral energy
Not easily predicted
Consider organ damage

Check impact side

Head, neck, upper arm,
shoulder, thorax,
abdomen, pelvis, legs

Courtesy of Bonnie Meneely, EMT-P

Scene Size-up - 22
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ

Rear-Impact Collision
Posterior displacement
Rapid forward deceleration
also possible

Headrest position
Hyperextension injuries

Damage back and front

Courtesy of Bonnie Meneely, EMT-P

Deceleration injuries
Scene Size-up - 23
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ

Rollover Collision
Multiple impacts
Multiple directions
Multiple injuries

Axial-loading injuries
Spine injury

Ejection

Courtesy of Bonnie Meneely, EMT-P

Chance of death
increases 25 times
Scene Size-up - 24
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ

Rotational Collision
Head-on, lateral-impact
combination
Converts forward motion
to spinning motion

Windshield, dashboard,
steering wheel, side
Same possible injuries
of both mechanisms
Scene Size-up - 25
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ

Occupant Restraint
Lap belt

Air bags

Clasp-knife effect

First impact only

Abdomen

Always lift and look

Lumbar spine

Three-point restraint
Cervical spine
Clavicular fracture
Scene Size-up - 26
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ

Tractor Accidents
One-third of farm fatalities
Side overturns 85%
Likely to throw clear

Rear overturns 15%

Likely to entrap or crush

Common injuries
Crush injuries
Thermal and chemical burns

Courtesy of Roy Alson, MD

Scene Size-up - 27
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ

Small-Vehicle Crashes
Small vehicles

Motorcycles
All-terrain vehicles
Personal watercraft
Snowmobiles

Factors
Protective gear
Additional impacts
Scene Size-up - 28
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ

Pedestrian Injuries
Mechanism
Primary collision
Additional impacts

Common injuries
Severe internal injuries
and fractures
Adult: bilateral leg, knee
Child: pelvis, torso

Courtesy of Bonnie Meneely, EMT-P

Scene Size-up - 29
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ

Falls
Vertical deceleration
Distance of fall
Anatomy impacted
Surface struck

Scene Size-up - 30
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ

Penetrating Injuries
Knife-wound severity
Anatomic area penetrated
Fourth intercostal space may
be chest and abdomen

Length of blade
Angle of penetration

Stabilize impaled object

Minimize external movement
Scene Size-up - 31
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ

Penetrating Injuries
Firearms
Type of weapon
Low-velocity
High-velocity

Caliber
Missile size
Bullet construction
Tumbling/yaw

Courtesy of Roy Alson, MD

Distance traveled
Scene Size-up - 32
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ

Penetrating Wounds
Entry wound
Smaller
May be darkened, burned

Exit wound
One, none, or many
Larger
May be ragged

Scene Size-up - 33
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ

Penetrating Wounds
Internal wound
Tissue contact damage
High-velocity transfer of energy
Shock waves
Temporary cavity
Pulsation of temporary cavity

Damage proportional to tissue density

Highly dense tissue sustains more damage
Scene Size-up - 34
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ

Blast Injuries
Primary
Initial air blast

Secondary
Material propelled

Tertiary
Impact on object

Quaternary

Courtesy of Roy Alson, MD

Dispersed hazardous
Scene Size-up - 35
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ

Caution

Do not approach until

Scene Size-up is complete!

Scene Size-up - 36
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ

Summary
Time is critical; teamwork is essential.
Scene size-up can be lifesaving.
Mechanism of injury:
An aid to predict injury
Part of overall management of trauma patient

Record scene and mechanism findings.

Scene Size-up - 37
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ

Discussion

Photo Jeff Forster

Scene Size-up - 38
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ