Module IV: Trauma

NREMT PRACTICE ANALYSIS TASK ITEMS
•	Perform a rapid trauma assessment 
•	Provide care to a patient with shock (hypoperfusion) 
•	Assess a patient with a head injury 
•	Assess a patient with a suspected spinal injury 
•	Provide care to a patient with a suspected spinal injury 
•	Provide care to a patient with a chest injury 
•	Provide care to a patient with a open abdominal injury 

Cognitive Objectives
At the completion of this unit, the paramedic will be able to:
4.1	State the reasons for performing a rapid trauma assessment. (C-1) / 3-3.35	
4.2	Recite examples and explain why patients should receive a rapid trauma assessment. (C-1) / 3-3.36	
4.3	Apply the techniques of physical examination to the trauma patient. (C-1) / 3-3.37	
4.4	Describe the areas included in the rapid trauma assessment and discuss what should be evaluated. (C-1) / 3-3.38	
4.5	Differentiate cases when the rapid assessment may be altered in order to provide patient care. (C-3) / 3-3.39	
4.6	Discuss the treatment plan and management of hemorrhage and shock. (C-1) / 4-2.8	
4.7	Develop, execute and evaluate a treatment plan based on the field impression for the hemorrhage or shock patient. (C-3) / 4-2.44	
4.8	Relate assessment findings associated with head/ brain injuries to the pathophysiologic process. (C-3) / 4-5.43	
4.9	Classify head injuries (mild, moderate, severe) according to assessment findings. (C-2) / 4-5.44	
4.10	Relate assessment findings associated with concussion, moderate and severe diffuse axonal injury to pathophysiology. (C-3) / 4-5.49	
4.11	Relate assessment findings associated with skull fracture to pathophysiology. (C-3) / 4-5.52	
4.12	Relate assessment findings associated with cerebral contusion to pathophysiology. (C-3) / 4-5.55	
4.13	Relate assessment findings associated with intracranial hemorrhage to pathophysiology, including: (C-3) / 4-5.58 
•	Epidural 
•	Subdural 
•	Intracerebral 
•	Subarachnoid 	
4.14	Integrate the pathophysiological principles to the assessment of a patient with head/ brain injury. (C-3) / 4-5.63	
4.15	Differentiate between the types of head/ brain injuries based on the assessment and history. (C-3) / 4-5.64	
4.16	Formulate a field impression for a patient with a head/ brain injury based on the assessment findings. (C-3) / 4-5.65	
4.17	Describe the assessment findings associated with spinal injuries. (C-1) / 4-6.6	
4.18	Identify the need for rapid intervention and transport of the patient with spinal injuries. (C-1) / 4-6.8	
4.19	Integrate the pathophysiological principles to the assessment of a patient with a spinal injury. (C-3) / 4-6.9	
4.20	Differentiate between spinal injuries based on the assessment and history. (C-3) / 4-6.10	
4.21	Formulate a field impression based on the assessment findings (spinal injuries). (C-3) / 4-6.11	
4.22	Develop a patient management plan based on the field impression (spinal injuries). (C-3) / 4-6.12	
4.23	Describe the assessment findings associated with traumatic spinal injuries. (C-1) / 4-6.14	
4.24	Describe the management of traumatic spinal injuries. (C-1) / 4-6.15	
4.25	Integrate pathophysiological principles to the assessment of a patient with a traumatic spinal injury. (C-3) / 4-6.16	
4.26	Differentiate between traumatic and non-traumatic spinal injuries based on the assessment and history. (C-3) / 4-6.17	
4.27	Formulate a field impression for traumatic spinal injury based on the assessment findings. (C-3) / 4-6.18	
4.28	Develop a patient management plan for traumatic spinal injury based on the field impression. (C-3) / 4-6.19	
4.29	Describe the assessment findings associated with non-traumatic spinal injuries. (C-1) / 4-6.21	
4.30	Describe the management of non-traumatic spinal injuries. (C-1) / 4-6.22	
4.31	Integrate pathophysiological principles to the assessment of a patient with non-traumatic spinal injury. (C-3) / 4-6.23	
4.32	Differentiate between traumatic and non-traumatic spinal injuries based on the assessment and history. (C-3) / 4-6.24	
4.33	Formulate a field impression for non-traumatic spinal injury based on the assessment findings. (C-3) 4-6.25	
4.34	Develop a patient management plan for non-traumatic spinal injury based on the field impression. (C-3) / 4-6.26	
4.35	Discuss the management of thoracic injuries. (C-1) / 4-7.7	
4.36	Identify the need for rapid intervention and transport of the patient with chest wall injuries. (C-1) / 4-7.11	
4.37	Discuss the management of chest wall injuries. (C-1) / 4-7.12	
4.38	Discuss the management of lung injuries. (C-1) / 4-7.15	
4.39	Identify the need for rapid intervention and transport of the patient with lung injuries. (C-1) / 4-7.16	
4.40	Discuss the management of myocardial injuries. (C-1) / 4-7.19	
4.41	Identify the need for rapid intervention and transport of the patient with myocardial injuries. (C-1) / 4-7.20	
4.42	Discuss the management of vascular injuries. (C-1) / 4-7.23	
4.43	Identify the need for rapid intervention and transport of the patient with vascular injuries. (C-1) / 4-7.24	
4.44	Discuss the management of diaphragmatic injuries. (C-1) / 4-7.27	
4.45	Identify the need for rapid intervention and transport of the patient with diaphragmatic injuries. (C-1) / 4-7.28	
4.46	Discuss the management of esophageal injuries. (C-1) / 4-7.31	
4.47	Identify the need for rapid intervention and transport of the patient with esophageal injuries. (C-1) / 4-7.32	
4.48	Discuss the management of tracheo-bronchial injuries. (C-1) / 4-7.35	
4.49	Identify the need for rapid intervention and transport of the patient with tracheo-bronchial injuries. (C-1) / 4-7.36	
4.50	Discuss the management of traumatic asphyxia. (C-1) / 4-7.39	
4.51	Identify the need for rapid intervention and transport of the patient with traumatic asphyxia. (C-1) / 4-7.40	
4.52	Develop a patient management plan based on the field impression (thoracic injuries). (C-3) / 4-7.44	
4.53	Describe the management of abdominal injuries. (C-1) / 4-8.8	
4.54	Develop a patient management plan for patients with abdominal trauma based on the field impression. (C-3) / 4-8.12	
4.55	Formulate a field impression based upon the assessment findings for a patient with abdominal injuries. (C-3) / 4-8.36	
4.56	Develop a patient management plan for a patient with abdominal injuries, based upon field impression. (C-3) / 4-8.37	

Psychomotor Objectives
At the completion of this unit, the paramedic will be able to:
4.57	Using the techniques of physical examination, demonstrate the assessment of a trauma patient. (P-2) / 3-3.77	
4.58	Demonstrate the rapid trauma assessment used to assess a patient based on mechanism of injury. (P-2) / 3-3.78	
4.59	Demonstrate the management of a patient with signs and symptoms of hemorrhagic shock. (P-2) / 4-2.46	
4.60	Demonstrate the management of a patient with signs and symptoms of compensated hemorrhagic shock. (P-2) / 4-2.48	
4.61	Demonstrate the management of a patient with signs and symptoms of decompensated hemorrhagic shock. (P-2) / 4-2.50	
4.62	Demonstrate a clinical assessment to determine the proper management modality for a patient with a suspected traumatic spinal injury. (P-1) / 4-6.29	
4.63	Demonstrate a clinical assessment to determine the proper management modality for a patient with a suspected non-traumatic spinal injury. (P-1) / 4-6.30	
4.64	Demonstrate immobilization of the urgent and non-urgent patient with assessment findings of spinal injury from the following presentations: (P-1) / 4-6.31 
•	Supine 
•	Prone 
•	Semi-prone 
•	Sitting 
•	Standing 	
4.65	Demonstrate preferred methods for stabilization of a helmet from a potentially spine injured patient. 4-6.33	
4.66	Demonstrate the following techniques of management for thoracic injuries: (P-1) / 4-7.50 
•	Needle decompression 
•	Fracture stabilization 
•	Elective intubation 
•	ECG monitoring 
•	Oxygenation and ventilation 	
4.67	Demonstrate a clinical assessment to determine the proper treatment plan for a patient with suspected abdominal trauma. (P-1) / 4-8.41	

Declarative
I.	Focused history and physical exam - trauma patients 
A.	Re-consider mechanism of injury 
1.	Helps to identify priority patients 
2.	Helps to guide the assessment 
3.	Significant mechanism of injury 
a.	Ejection from vehicle 
b.	Death in same passenger compartment 
c.	Falls > 20 feet 
d.	Roll-over of vehicle 
e.	High-speed vehicle collision 
f.	Vehicle-pedestrian collision 
g.	Motorcycle crash 
h.	Unresponsive or altered mental status 
i.	Penetrations of the head, chest, or abdomen 
j.	Hidden injuries 
i.	Seat belts 
a.	If buckled, may have produced injuries 
b.	If patient had seat belt on, it does not mean they do not have injuries 
ii.	Airbags 
a.	May not be effective without seat belt 
b.	Patient can hit wheel after deflation 
c.	Lift the deployed airbag and look at the steering wheel for deformation 
4.	Additional infant and child considerations 
a.	Falls >10 feet 
b.	Bicycle collision 
c.	Vehicle in medium speed collision 
B.	Perform rapid trauma physical examination on patients with significant mechanism of injury to determine life-threatening injuries 
1.	In the responsive patient, symptoms should be sought before and during the trauma assessment 
2.	Continue spinal stabilization 
3.	Reconsider transport decision 
4.	Assess mental status 
5.	As you inspect and palpate, look and feel for injuries or signs of injury 
6.	Examination 
a.	Assess the head, inspect and palpate for injuries or signs of injury 
b.	Assess the neck, inspect and palpate for injuries or signs of injury 
c.	Apply cervical spinal immobilization collar (CSIC) (may use information from the head injury unit at this time) 
d.	Assess the chest 
e.	Assess the abdomen, inspect and palpate for injuries or signs of injury 
f.	Assess the pelvis, inspect and palpate for injuries or signs of injury 
g.	Assess all four extremities, inspect and palpate for injuries or signs of injury 
h.	Roll patient with spinal precautions and assess posterior body, inspect and palpate, examining for injuries or signs of injury 
i.	Look for medical identification devices 
j.	Assess baseline vital signs 
k.	Assess patient history 
l.	Chief complaint 
m.	History of present illness 
n.	Past medical history 
o.	Current health status 
II.	Shock 
A.	Epidemiology 
B.	Pathophysiology 
C.	Stages of Shock 
D.	Assessment 
E.	Management/ treatment plan 
1.	Airway and ventilatory support 
a.	Ventilate and suction as necessary 
b.	Administer high concentration oxygen 
c.	Reduce increased intrathoracic pressure in tension pneumothorax 
2.	Circulatory support 
a.	Hemorrhage control 
b.	Intravenous volume expanders 
i.	Types 
a.	Isotonic solutions 
b.	Hypertonic solutions 
c.	Synthetic solutions 
d.	Blood and blood products 
e.	Experimental solutions 
f.	Blood substitutes 
ii.	Rate of administration 
a.	External hemorrhage that can be controlled 
b.	External hemorrhage that can not be controlled 
c.	Internal hemorrhage 
c.	Pneumatic anti-shock garment 
i.	Effects 
a.	Increased arterial blood pressure above garment 
b.	Increased systemic vascular resistance 
c.	Immobilization of pelvis and possibly lower extremities 
d.	Increased intra-abdominal pressure 
ii.	Mechanism 
a.	Increases systemic vascular resistance through direct compression of tissues and blood vessels 
b.	Negligible autotransfusion effect 
iii.	Indications 
a.	Hypoperfusion with unstable pelvis 
b.	Conditions of decreased SVR not corrected by other means 
c.	As approved locally, other conditions characterized by hypoperfusion with hypotension 
d.	Research studies 
iv.	Contraindications 
a.	Advanced pregnancy (no inflation of abdominal compartment) 
b.	Object impaled in abdomen or evisceration (no inflation of abdominal compartment) 
c.	Ruptured diaphragm 
d.	Cardiogenic shock 
e.	Pulmonary edema 
v.	Needle chest decompression of tension pneumothorax to improve impaired cardiac output 
vi.	Recognize the need for expeditious transport of suspected cardiac tamponade for pericardiocentesis 
3.	Pharmacological interventions 
a.	Hypovolemic shock 
i.	Volume expanders 
b.	Cardiogenic shock 
i.	Volume expanders 
ii.	Positive cardiac inotropes 
iii.	Vasoconstrictor 
iv.	Rate altering medications 
c.	Distributive shock 
i.	Volume expanders 
ii.	Positive cardiac inotropes 
iii.	Vasoconstriction 
iv.	PASG 
d.	Obstructive shock 
i.	Volume expanders 
e.	Spinal shock 
i.	Volume expanders 
4.	Psychological support/communication strategies 
5.	Transport considerations 
a.	Indications for rapid transport 
b.	Indications for transport to a trauma center 
c.	Considerations for air medical transportation 
III.	Head trauma 
A.	Review of anatomy and physiology 
B.	Mechanisms of injury 
C.	General categories of injury 
D.	Causes of brain injury 
E.	Head injury – broad and inclusive 
F.	Brain injury 
G.	Pathophysiology of head/brain injury 
1.	Increased intracranial pressure 
2.	Mechanism 
3.	Assessment 
a.	Pressure exerted downward 
i.	Cerebral cortices and/ or reticular activating system effected 
a.	Altered level of consciousness - amnesia of event, confusion, disorientation, lethargy or combativeness, focal deficit or weakness 
ii.	Hypothalamus - vomiting 
iii.	Brain stem 
a.	Blood pressure elevates to maintain MAP and thus CPP 
b.	Vagal nerve pressure - bradycardia 
c.	Respiratory centers - irregular respirations or tachypnea 
d.	Oculomotor nerve paralysis - unequal/ unreactive pupils 
e.	Posturing - flexion/ extension 
iv.	Seizures - depending on location of injury 
b.	Levels of increasing ICP 
i.	Cerebral cortex and upper brain stem involved 
a.	BP rising and pulse rate begins slowing 
b.	Pupils still reactive 
c.	Cheyne-Stokes respirations 
d.	Initially try to localize and remove painful stimuli 
e.	All effects reversible at this stage 
ii.	Middle brain stem involved 
a.	Wide pulse pressure and bradycardia 
b.	Pupils nonreactive or sluggish 
c.	Central neurogenic hyperventilation (CNH) 
d.	Extension 
e.	Few patients function normally from this level 
iii.	Lower portion of brain stem involved/ medulla 
a.	Pupil blown - same side as injury 
b.	Respirations ataxic (erratic, no rhythm) or absent 
c.	Flaccid 
d.	Labile pulse rate, irregular often great pulse swings in rate 
e.	QRS, S-T and T wave changes 
f.	Decreased BP, often labile BP 
g.	Not considered survivable 
c.	Glasgow coma scale - method to assess level of consciousness 
i.	Three independent measurements 
a.	Eye opening 
b.	Verbal response 
c.	Motor response 
ii.	Numerical score - 3 to 15 
iii.	Head injury classified according to score 
a.	Mild - 13 to 15 
b.	Moderate - 8 to 12 
c.	Severe - < 8 
d.	Vital signs 
e.	Pupil size and reaction 
f.	Presence of focal deficit 
g.	History of unconsciousness or amnesia of event 
iv.	Management 
H.	Specific Injuries - diffuse axonal injury and focal injuries 
1.	Diffuse axonal injury - shearing, stretching or tearing of nerve fibers with subsequent axonal damage 
a.	Concussion (mild DAI) - physiologic neurologic dysfunction without substantial anatomic disruption which results in transient episode of neuronal dysfunction with rapid return to normal neurologic activity 
i.	Epidemiology 
ii.	Assessment - confusion, disorientation, amnesia of the event 
iii.	Management 
2.	Moderate DAI - shearing, stretching or tearing results in minute petechial bruising of brain tissue, brain stem and reticular activating system may be involved leading to unconsciousness 
a.	Epidemiology 
b.	Assessment - may result in immediate unconsciousness or persistent confusion, disorientation and amnesia of the event extending to amnesia of moment-to-moment events; may have focal deficit; residual cognitive (inability to concentrate), psychologic (frequent periods of anxiety, uncharacteristic mood swings) and sensorimotor deficits (sense of smell altered) may persist 
c.	Management 
3.	Severe DAI - formerly called brain stem injury, involves severe mechanical disruption of many axons in both cerebral hemispheres and extending to the brainstem 
a.	Epidemiology 
b.	Assessment - unconsciousness for prolonged period, posturing common, other signs of increased ICP occur depending on various degrees of damage 
c.	Management 
4.	Focal injury 
a.	Skull fracture - the significance is in the amount of force involved 
i.	Epidemiology 
ii.	Types 
a.	Linear (80% of all skull fractures) 
b.	Depressed 
c.	Basilar 
d.	Open skull fractures 
iii.	Assessment - linear fractures may be missed, depressed and open skull fractures usually found on palpation of head, use balls of fingers to palpate 
a.	Airway patency and breathing adequacy a priority 
b.	Vomiting and inadequate respirations are common 
c.	Assess for signs and symptoms of increased intracranial pressure 
i.	Management 
a.	Cerebral contusion - a focal brain injury in which brain tissue is bruised and damaged in a local area; may occur at both the area of direct impact (coup) and/or on the opposite side (contrecoup) of impact 
i.	Epidemiology 
ii.	Assessment 
a.	Airway patency and breathing adequacy a priority 
b.	Alteration in level of consciousness 
c.	May complain of progressive headache and/ or photophobia 
d.	May be unable to lay down memory - repetitive phrases common 
e.	Assess for signs and symptoms of increased intracranial pressure 
iii.	Management 
b.	Intracranial hemorrhage 
i.	Types 
a.	Epidural 
b.	Subdural 
c.	Intracerebral 
d.	Subarachnoid 
ii.	Epidemiology 
iii.	Assessment 
a.	May be impossible to tell which type of hematoma is present 
b.	More important to recognize the presence of brain injury 
c.	Signs/ symptoms of increasing intracranial pressure 
d.	Signs/ symptoms of neurological deficit 
e.	Early signs and symptoms of alterations in level of consciousness 
f.	Signs of brain irritation - change in personality, irritability, lethargy, confusion, repeating words or phrases, changes in consciousness, paralysis of one side of the body, seizures 
g.	GCS 
iv.	Management 
I.	Spinal trauma 
A.	Introduction 
B.	Incidences 
C.	Morbidity and mortality 
D.	Traditional spinal assessments/ criteria 
1.	Based upon mechanism of injury (MOI) 
2.	Past emphasis for spinal immobilization considerations 
a.	Unconscious accident victims 
b.	Conscious accident victims checked for SCI prior to movement 
c.	Any patient with a "motion" injury 
3.	Lack of clear clinical guidelines or specific criteria to evaluate for SCI 
4.	Signs which may indicate SCI 
a.	Pain 
b.	Tenderness 
c.	Painful movement 
d.	Deformity 
e.	Cuts/ bruises (over spinal area) 
f.	Paralysis 
g.	Paresthesias 
h.	Paresis (weakness) 
i.	Shock 
j.	Priapism 
5.	Not always practical to immobilize every "motion" injury 
6.	Most suspected injuries were moved to a normal anatomical position 
a.	Lying flat on a spine board 
b.	No exclusion criteria used for moving patients to an anatomical position 
7.	Need to have clear criteria to assess for the presence of SCI 
E.	General spinal anatomy and physiology review 
F.	General assessment of spinal injuries 
1.	Determine mechanism of injury/ nature or injury 
a.	Positive MOI 
i.	Always requires full spinal immobilization 
a.	High speed motor vehicle crash(es) 
b.	Falls greater than three times patient’s height 
c.	Violent situations occurring near the spine 
d.	Sports injuries 
e.	Other high impact situations 
ii.	Some medical directors may allow field personnel to not immobilize patients with MOI but without signs and/ or symptoms of a SCI 
a.	Based on assessment 
b.	Negative MOI 
i.	Forces or impact involved does not suggest a potential spinal injury 
ii.	Does not require spinal immobilization 
a.	Examples 
c.	Uncertain MOI 
i.	Unclear or uncertainty regarding the impact or forces 
ii.	Clinical criteria used for a basis of whether to employ spinal immobilization 
a.	Examples 
d.	Clinical criteria versus mechanism of injury 
i.	Initial management 
a.	Based solely upon MOI 
ii.	Positive MOI 
a.	Spine immobilization 
iii.	Negative MOI 
a.	Without signs or symptoms 
iv.	Uncertain MOI 
a.	Need for further clinical assessment and evaluation 
v.	In some non-traumatic spinal conditions immobilization may be necessary/indicated 
vi.	Altered LOC or unconsciousness requires spine stabilization 
G.	Assessment of uncertain MOIs 
1.	Specific clinical criteria 
a.	Necessary to assess when electing not to immobilize a trauma patient 
b.	Begins with patient reliability 
i.	Continually reassessed during specific exam 
c.	If specific criteria cannot be clearly satisfied; complete spine immobilization undertaken 
d.	Positive MOI always equals spine immobilization 
i.	This specific assessment may still be used to determine level of injury 
2.	Specific criteria 
a.	Prevent motion of the spine by assistant maintaining stabilization throughout the exam 
b.	Reliable patients/ exam 
i.	In order for assessments of pain, tenderness, motor, and sensory function to be accurate the patient must be reliable 
ii.	Patient must be 
a.	Calm 
b.	Cooperative 
c.	Sober 
d.	Alert and oriented 
iii.	Unreliable patient defined 
a.	Acute stress reaction 
b.	Brain injury 
c.	Intoxication 
d.	Abnormal mental status 
e.	Distracting injuries 
f.	Communication problems 
iv.	Unreliable indicators present 
a.	Full spinal immobilization indicated 
c.	Assess for spinal pain 
i.	Patient is asked about 
a.	Any related spinal pain 
b.	Signs 
c.	Symptoms 
ii.	May be poorly localized 
iii.	Might not feel directly over the spinous process 
iv.	Pain with active movement of head and neck 
a.	Patient is asked to slowly move their head and neck 
b.	If any pain occurs 
d.	Assess for spine tenderness 
i.	Palpate over each of the spinous processes of the vertebra 
ii.	Begin at the neck and work towards the pelvis 
iii.	May be beneficial to palpate back up from the pelvis to the neck 
e.	Upper extremity neurological function assessment 
i.	Motor function 
a.	Finger abduction/ adduction 
b.	Finger/ hand extension 
ii.	Sensory function 
a.	Pain sensation 
f.	Lower extremity neurological function assessment 
i.	Motor function 
a.	Foot plantar flexion 
b.	Foot/ great toe dorsiflexion 
ii.	Sensory function 
a.	Pain sensation 
g.	General motor function assessment 
i.	Tests nerve roots at both cervical and lumbar/ sacral spine levels 
ii.	Check two sets of nerve roots at each level as well as left and right sides 
iii.	Able to determine most clinical patterns of SCI 
iv.	Motor exams can to be completed even if local injury exists 
a.	If exam cannot be completed due to local injury entire exam is unreliable 
h.	Sensory function assessment 
i.	Test (exam) sensory 
a.	At cervical and lumbar/ sacral spine levels 
ii.	Sensory exam will detect clinical patterns of SCI 
iii.	Any signs or symptoms of abnormal sensation 
a.	Spinal immobilization indicated 
H.	General management of spinal injuries 
1.	Principles of spinal immobilization 
a.	Primary goal is to prevent further injury 
b.	Treat spine as a long bone with a joint at either end (head and pelvis) 
c.	15% of secondary spinal injuries are preventable with proper immobilization 
d.	Always use "complete" spine immobilization 
i.	Impossible to isolate and splint specific injury site 
e.	Spine stabilization begins in the initial assessment 
i.	Continues until the spine is completely immobilized on a long backboard 
f.	Head and neck should be placed in a neutral, in-line position unless contraindicated 
i.	Neutral positioning allows for the most space for the cord 
a.	Reducing cord hypoxia 
b.	Reducing excess pressure 
ii.	Most stable position for the spinal column 
a.	Reduces instability 
2.	Spinal stabilization/ immobilization 
a.	Systematic approach 
i.	Cervical immobilization 
a.	Manual 
b.	Rigid collar 
ii.	Interim immobilization device 
a.	When indicated (vest type mobilization device, short backboard) 
b.	Movement of a stable patient from a seated position to a long backboard 
iii.	Long backboard 
iv.	Full body vacuum splints 
v.	Padding (body shims) 
a.	Use to maintain anatomical position 
b.	Limits movement of patient 
c.	Fill all voids 
d.	Pillows 
e.	Towels 
f.	Blankets 
vi.	Straps 
a.	Sufficient to immobilize to the long backboard 
vii.	Cervical immobilization device 
a.	Commercial 
b.	Tape 
c.	Blanket roll 
d.	Pillows 
b.	Helmeted patients 
i.	Special assessment needs for patients wearing helmets 
ii.	Indications for leaving the helmet in place 
iii.	Indications for helmet removal 
iv.	Types of helmets 
v.	General guidelines for helmet removal 
II.	Thoracic trauma 
A.	General Introduction 
1.	Epidemiology 
2.	Mechanism of injury 
3.	Anatomy and physiology review of the thorax 
4.	Pathophysiology 
5.	Assessment findings 

6.	Management 
a.	Airway and ventilation 
i.	Oxygen therapy 
ii.	Endotracheal intubation 
iii.	Needle cricothyrotomy 
iv.	Surgical cricothyrotomy 
v.	Positive pressure ventilation 
vi.	Occlude open wounds 
vii.	Stabilize chest wall 
b.	Circulation 
i.	Manage cardiac dysrhythmias 
ii.	Intravenous access 
c.	Pharmacologic 
i.	Analgesics 
ii.	Antiarrhythmics 
d.	Non-pharmacologic 
i.	Needle thoracostomy 
ii.	Tube thoracostomy - in hospital management 
iii.	Pericardiocentesis - in hospital management 
e.	Transport considerations 
i.	Appropriate mode 
ii.	Appropriate facility 
B.	Chest wall injuries 
1.	Rib fractures 
a.	Epidemiology 
b.	Anatomy and physiology review 
c.	Pathophysiology 
d.	Assessment findings 
e.	Management 
i.	Airway and ventilation 
a.	Oxygen therapy 
b.	Positive pressure ventilation 
c.	Encourage coughing and deep breathing 
ii.	Pharmacological 
a.	Analgesics 
iii.	Non-pharmacological 
a.	Splint - but avoid circumferential splinting 
iv.	Transport consideration 
a.	Appropriate mode 
b.	Appropriate facility 
v.	Psychological support/ communication strategies 
2.	Flail segment 
a.	Epidemiology 
b.	Pathophysiology 
c.	Assessment findings 
d.	Management 
i.	Airway and ventilation 
a.	Positive pressure ventilation may be needed 
b.	Oxygen (high concentration) 
c.	Evaluate the need for endotracheal intubation 
d.	Stabilize flail segment (may be controversial locally) 
e.	Positive end expiratory pressure (PEEP) 
ii.	Circulation 
a.	Restrict fluids 
iii.	Pharmacologic 
a.	Analgesics 
iv.	Non-pharmacologic 
a.	Positioning 
b.	Endotracheal intubation and positive pressure ventilation for internal splinting effect 
v.	Transport considerations 
a.	Appropriate mode 
b.	Appropriate facility 
vi.	Psychological support/ communication strategies 
3.	Sternal fracture 
a.	Epidemiology 
b.	Pathophysiology 
c.	Assessment findings 
d.	Management 
i.	Airway and ventilation 
ii.	Circulation 
a.	Restrict fluids if pulmonary contusion is suspected 
iii.	Pharmacologic 
a.	Analgesics 
iv.	Non-pharmacologic 
a.	Allow chest wall self-splinting 
v.	Transport considerations 
a.	Appropriate mode 
b.	Appropriate facility 
vi.	Psychological support/ communication strategies 
C.	Injury to the lung 
1.	Simple pneumothorax 
a.	Epidemiology 
b.	Pathophysiology 
c.	Assessment findings 
d.	Management 
i.	Airway and ventilation 
a.	Positive pressure ventilation if necessary 
b.	Monitor for development of tension pneumothorax 
ii.	Non-pharmacologic 
a.	Needle thoracostomy 
iii.	Transport consideration 
a.	Appropriate mode 
b.	Appropriate facility 
e.	Psychological support/ communication strategies 
2.	Open pneumothorax 
a.	Epidemiology 
b.	Pathophysiology 
c.	Assessment findings 
d.	Management 
i.	Airway and ventilation 
a.	Positive pressure ventilation if necessary 
b.	Monitor for development of tension pneumothorax 
ii.	Non-pharmacologic 
a.	Occlude open wound 
b.	Tube thoracostomy - in hospital management 
e.	Transport consideration 
i.	Appropriate mode 
ii.	Appropriate facility 
f.	Psychological support/ communication strategies 
3.	Tension pneumothorax 
a.	Epidemiology 
b.	Pathophysiology 
c.	Assessment findings 
d.	Management 
i.	Airway and ventilation 
a.	Positive pressure ventilation if necessary 
ii.	Circulation 
a.	Relieve tension pneumothorax to improve cardiac output 
iii.	Non-pharmacologic 
a.	Occlude open wound 
b.	Needle thoracentesis 
c.	Tube thoracostomy - in hospital management 
iv.	Transport consideration 
a.	Appropriate mode 
b.	Appropriate facility 
v.	Psychological support/ communication strategies 
4.	Hemothorax 
a.	Epidemiology 
b.	Pathophysiology 
c.	Assessment findings 
d.	Management 
i.	Airway and ventilation 
a.	Positive pressure ventilation if necessary 
ii.	Circulation 
a.	Re-expand the affected lung to reduce bleeding 
iii.	Non-pharmacological 
a.	Needle chest decompression 
b.	Tube thoracostomy - in hospital management 
iv.	Transport considerations 
a.	Appropriate mode 
b.	Appropriate facility 
v.	Psychological support/ communication strategies 
5.	Hemopneumothorax 
a.	Epidemiology 
b.	Pathophysiology 
c.	Assessment findings 
d.	Management 
i.	Management is the same as a hemothorax 
6.	Pulmonary contusion 
a.	Epidemiology 
b.	Pathophysiology 
c.	Assessment findings 
d.	Management 
i.	Airway and ventilation 
a.	Positive pressure ventilation if necessary 
ii.	Circulation 
a.	Restrict intravenous fluids (use caution restricting fluids in hypovolemic patients) 
iii.	Transport considerations 
a.	Appropriate mode 
b.	Appropriate facility 
iv.	Psychological support/ communication strategies 
D.	Myocardial injuries 
1.	Pericardial tamponade 
a.	Epidemiology 
b.	Anatomy and physiology 
c.	Pathophysiology 
d.	Assessment findings 
e.	Management 
i.	Airway and ventilation 
ii.	Circulation 
a.	Fluid challenge 
iii.	Non-pharmacological 
a.	Pericardiocentesis - in hospital management 
iv.	Transport considerations 
a.	Appropriate mode 
b.	Appropriate facility 
v.	Psychological support/ communication strategies 
2.	Myocardial contusion (blunt myocardial injury) 
a.	Epidemiology 
b.	Anatomy and physiology 
c.	Pathophysiology 
d.	Assessment findings 
e.	Management 
i.	Airway and ventilation 
a.	Oxygen therapy 
ii.	Circulation 
a.	Intravenous fluid volume 
iii.	Pharmacological 
a.	Antiarrhythmics 
b.	Vasopressors 
iv.	Transport considerations 
a.	Appropriate mode 
b.	Appropriate facility 
v.	Psychological support/ communication strategies 
3.	Myocardial rupture 
a.	Epidemiology 
b.	Anatomy and physiology 
c.	Pathophysiology 
d.	Assessment findings 
e.	Management is supportive 
E.	Vascular injuries 
1.	Aortic dissection/ rupture 
a.	Epidemiology 
b.	Anatomy and physiology 
c.	Pathophysiology 
d.	Assessment findings 
e.	Management 
i.	Airway and ventilation 
ii.	Circulation 
a.	Do not over hydrate 
iii.	Transport considerations 
a.	Appropriate mode 
b.	Appropriate facility 
iv.	Psychological support/ communication strategies 
2.	Penetrating wounds of the great vessels 
a.	Epidemiology 
b.	Anatomy and physiology 
c.	Pathophysiology 
d.	Assessment findings

e.	Management 
i.	Manage hypovolemia 
a.	PASG not recommended 
ii.	Relief of tamponade if present 
iii.	Expeditious transport 
F.	Other thorax injuries 
1.	Diaphragmatic injury 
a.	Epidemiology 
b.	Pathophysiology 
c.	Assessment 
d.	Management 
i.	Airway and ventilation 
a.	Positive pressure ventilation if necessary 
b.	Caution IPPB may worsen the injury 
ii.	Non-pharmacologic 
a.	Do not place patient in Trendelenburg position 
iii.	Transport consideration 
a.	Appropriate mode 
b.	Appropriate facility 
iv.	Psychological support/ communication strategies 
2.	Esophageal injury 
a.	Epidemiology 
b.	Pathophysiology 
c.	Assessment 
d.	Management 
i.	Airway and ventilation 
ii.	Transport consideration 
a.	Appropriate mode 
b.	Appropriate facility 
iii.	Psychological support/ communication strategies 
3.	Tracheo-bronchial injuries 
a.	Epidemiology 
b.	Pathophysiology 
c.	Assessment 
d.	Management 
i.	Airway and ventilation 
ii.	Circulation 
iii.	Transport consideration 
a.	Appropriate mode 
b.	Appropriate facility 
4.	Traumatic asphyxia 
a.	Epidemiology 
b.	Pathophysiology 
c.	Assessment 
d.	Management 
i.	Airway and ventilation 
ii.	Circulation 
a.	Expect hypotension once compression is released 
iii.	Pharmacological 
a.	Sodium bicarbonate should be guided by ABGs in hospital 
iv.	Transport considerations 
a.	Appropriate mode 
b.	Appropriate facility 

III.	Abdominal trauma 
A.	General introduction 
1.	Epidemiology 
2.	Anatomy review 
3.	Mechanism of injury review 
B.	General system pathophysiology, assessment, and management 
1.	Pathophysiology of abdominal injuries 
2.	Assessment 
3.	Management/ treatment plan 
a.	Surgical intervention only effective therapy 
b.	No definitive therapy possible out-of-hospital 
c.	Rapid evaluation 
d.	Initiation of shock resuscitation 
e.	Rapid packaging and transport to nearest appropriate facility 
i.	Facility must have immediate surgical capability 
ii.	Rapid transport 
a.	Defeated if hospital cannot provide immediate surgical intervention 
iii.	Crystalloid fluid replacement 
a.	En route to hospital 
iv.	Airway support 
v.	Breathing support 
vi.	Circulatory support 
a.	Control obvious hemorrhage 
b.	Tamponade bleeding 
c.	Manage hypotension 
vii.	Patient packaging 
viii.	Transport 
a.	Indications for rapid transport 
b.	Indications for transport to trauma center 
c.	Indications for transport to acute care facility 
d.	Indications for no transport required 
C.	Specific injuries 
1.	Solid organ injuries 
a.	Overview 
i.	Epidemiology 
ii.	Prevention strategies 
iii.	Anatomy and physiology review 
iv.	Pathophysiology 
v.	Assessment 
vi.	Management/ treatment plan 
a.	Airway support 
b.	Breathing support 
c.	Circulatory support 
d.	Patient packaging 
e.	Transport 
f.	Psychological support/ communications strategies 
b.	Liver injuries 
i.	Morbidity and mortality 
a.	Result of blood loss 
ii.	Injuries result of 
a.	Blunt trauma 
b.	Penetrating trauma 
c.	Splenic injuries 
i.	Most frequently injured organ 
a.	Blunt trauma 
b.	Commonly associated with other intra abdominal injuries 
c.	May present with left shoulder pain 
d.	Kidney injuries 
i.	Often presents with hematuria 
ii.	Back pain 
e.	Pancreas 
i.	Most common with penetrating injuries 
ii.	May also occur as a result of pancreas being compressed against vertebral column by 
a.	Steering wheels 
b.	Handle bars 
c.	Other structures stronger then the pancreas 
iii.	Products of pancreas have an irritation effect on peritoneum 
iv.	Auto-digestion of tissue 
f.	Diaphragm 
i.	Injury often insidious 
ii.	Herniation of abdominal contents into chest may occur 
2.	Hollow organ injuries 
a.	Overview 
i.	Epidemiology 
ii.	Prevention strategies 
iii.	Anatomy and physiology review 
iv.	Pathophysiology 
v.	Assessment 
vi.	Management/ treatment plan 
a.	Airway support 
b.	Breathing support 
c.	Circulatory support 
d.	Patient packaging 
e.	Transport 
f.	Psychological support/ communications strategies 
b.	Small and large intestines 
i.	Most often injured as a result of penetrating injuries 
ii.	Can occur with deceleration injuries 
c.	Stomach 
i.	Most often injured as a result of 
a.	Blunt trauma 
b.	Full stomach prior to incident increases risk of injury 
d.	Duodenum 
i.	Most often injured as a result of 
a.	Blunt trauma 
ii.	Recognition often delayed 
e.	Bladder 
i.	Most often injured as a result of 
a.	Blunt trauma 
b.	Full bladder prior to incident may increase risk of injury 
ii.	Associated with pelvic injury 
3.	Abdominal vascular injuries 
a.	Overview 
i.	Epidemiology 
ii.	Prevention strategies 
iii.	Anatomy and physiology review 
iv.	Pathophysiology 
v.	Assessment 
vi.	Management/ treatment plan 
a.	Airway support 
b.	Breathing support 
c.	Circulatory support 
d.	Patient packaging 
e.	Transport 
f.	Psychological support/ communications strategies 
4.	Other related abdominal injuries 
a.	Eviscerations 
i.	Epidemiology 
ii.	Prevention strategies 
iii.	Anatomy and physiology review 
iv.	Pathophysiology 
v.	Assessment 
vi.	Management/ treatment plan 
a.	Airway support 
b.	Breathing support 
c.	Circulatory support 
d.	Patient packaging 
e.	Transport 
f.	Psychological support