01-chapter1 (scene size up)itls6thedinstructor 000

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

International Trauma Life Support

International Trauma Life Support

for Prehospital Care ProvidersSixth Edition

for Prehospital Care ProvidersSixth Edition

Patricia M. Hicks, MS, NREMTPRoy Alson, PhD, MD, FACEP

Donna Hastings, EMT-PJohn Emory Campbell, MD, FACEP

and Alabama Chapter,American College of Emergency Physicians

Patricia M. Hicks, MS, NREMTPRoy Alson, PhD, MD, FACEP

Donna Hastings, EMT-PJohn Emory Campbell, MD, FACEP

and Alabama Chapter,American College of Emergency Physicians

Chapter 1Scene Size-upChapter 1Scene Size-up


Courtesy of Bonnie Meneely, EMT-P

Scene Size-upScene Size-up


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

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Overview

Blast injury factors related to assessment

Collisions in motor-vehicle crashCollisions in motor-vehicle crash• Potential injuries related to vehicle damage

Common motor-vehicle crash 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

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Trauma

Scene Size-up - 5

For severely injured patients,For severely injured patients,

survival is time-dependent!survival is time-dependent!


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

Trauma Survival

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Trauma Care

Teamwork is important!

You must know:

• What you can handle and what you can’t

• What you should handle and what you shouldn’t

• When to stay and when to leave

• Fastest route there and fastest route away

• What to do, what not to do, and when to wait

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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.

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Scene Size-up

First step in ITLS Primary Survey

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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

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Standard Precautions

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Personal protective equipment is always needed at trauma scenes.Personal protective equipment is always needed at trauma scenes.


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

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Initial Triage

Total number of patients

• Call for backup

• Medical command

• Initiate MCI protocols

• Any more patients?

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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

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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

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Basic Motion Mechanisms

Blunt injuries• Rapid forward

deceleration

• Rapid vertical deceleration

• Blunt instrument energy transfer

Penetrating injuries• Projectiles

• Knives

• Falls upon objects

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Motor-Vehicle Collisions

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Each collision is three collisions:

Machine Collision1 Body

Collision2 Organ Collision3


Other Collisions

Secondary collisions• Objects are missiles

at original speed

Additional impacts• Vehicle collides

with another object

• Other vehicles collide with original vehicle

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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?

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Common Collisions

Common types

• Head-on

• Lateral-impact (T-bone)

• Rear-impact

• Rollover

• Rotational

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Head-on Collision

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Windshield injuries• Brain, soft-tissue injury,

cervical spine

Steering wheel injuries• Traumatic tattooing of skin

Dashboard injuries• Face, brain, cervical spine,

pelvis, hip, knee



Lateral-Impact Collision

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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



Rear-Impact Collision

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Posterior displacement• Rapid forward deceleration

also possible

Headrest position• Hyperextension injuries

Damage back and front• Deceleration injuries



Rollover Collision

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Multiple impacts• Multiple directions• Multiple injuries

Axial-loading injuries• Spine injury

Ejection• Chance of death

increases 25 times



Rotational Collision

Scene Size-up -

Head-on, lateral-impact combination• Converts forward motion

to spinning motion

Windshield, dashboard, steering wheel, side• Same possible injuries

of both mechanisms

25


Occupant Restraint

Lap belt• Clasp-knife effect

• Abdomen

• Lumbar spine

Three-point restraint• Cervical spine

• Clavicular fracture

Air bags• First impact only

• Always “lift and look”

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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

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Courtesy of Roy Alson, MD


Small-Vehicle Crashes

Small vehicles• Motorcycles• All-terrain vehicles • Personal watercraft• Snowmobiles

Factors• Protective gear• Additional impacts

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Pedestrian Injuries

Mechanism• Primary collision• Additional impacts

Common injuries• Severe internal injuries

and fractures• Adult: bilateral leg, knee• Child: pelvis, torso

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Falls

Vertical deceleration

• Distance of fall

• Anatomy impacted

• Surface struck

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Penetrating Injuries

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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


Penetrating Injuries

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Firearms• Type of weapon

• Low-velocity• High-velocity

• Caliber• Missile size• Bullet construction• Tumbling/yaw

• Distance traveled



Penetrating Wounds

Entry wound• Smaller• May be darkened, burned

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

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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

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Blast Injuries

Primary• Initial air blast

Secondary• Material propelled

Tertiary• Impact on object

Quaternary • Dispersed hazardous

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Caution

Do not approach until

Scene Size-up is complete!

Do not approach until

Scene Size-up is complete!

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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.

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01-chapter1 (scene size up)itls6thedinstructor 000

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