Hands-On Trauma

Lecture Notes

These notes are designed to be used as a basis for a talk for between 30 minutes and an hour, aimed at an audience with a range of skills between basic CPR and EMT-B. Appropriate visual aids should be added. I've included some suggestions for practical demonstrations.

Introduction

What is trauma?

Two main ways of harm coming to a person:
- From the inside e.g. poisoning, heart attack, diabetes
- From the outside e.g. violence, sudden deceleration
The latter is what we call trauma
Trauma can be subdivided into blunt and penetrating

Why should it concern us?

Causes injuries to otherwise healthy people
Injuries have potential to be very serious
Often, simple first aid can save lives

What are the fundamental principles of treatment?

Nothing changes! DRSABC
In addition, however, guard the C-spine
Be especially careful of danger; often, the cause is still present and threatens the first aiders
Don't stop when you've just found one injury

What about time on-scene?

"Golden Hour" -- most critical period for casualty is first hour after injury
"Platinum 10 Minutes" -- 10 mins for ambulance crew on-scene to prioritise, treat and start transport of casualties

Causes Of Trauma

Blunt trauma:

Caused by hitting / being hit by a large, heavy or fast object
Examples:
- Car accident (rapid deceleration against steering wheel)
- Fall from a height (rapid deceleration against ground)
- Manual violence (fist, baseball bat)
A car accident is pretty much the definitive blunt trauma situation

Penetrating trauma:

Categorised by velocity
Low velocity: knives, shards of glass from falling through window
Medium velocity: bullets from pistols, blast shrapnel
High velocity (supersonic): bullets from rifles

Injuries From Trauma

The "Kill-Zone":

Head:
- Skull fracture from direct/indirect impact
- Bleeding in brain causing compression
- Blocked airway from mouth/jaw injuries
- Blocked airway from unconsciousness
Neck/Spine:
- Vertebra fracture/dislocation from direct/indirect impact
- Spinal cord injury from contact with fracture zone
Chest:
- Heart
  - Physical tearing from penetration
  - Bleeding inside sac (tamponade)
  - Heart beating irregular or stopped by damage to heart surface
  - Cardiac shock from damage to heart
- Lungs
  - Collapsed lung from penetration
  - Blood in lungs from penetration
  - Burst lungs from "paper bag" effect
  - Compression of heart and collapse of lungs from tension pneumothorax
- Blood vessels
  - Rupture of aorta or vena cava from deceleration
  - Ripping of vessels by penetration
  - Shock from loss of blood
Abdomen:
- Internal bleed from rupture of organ (spleen is favourite)
- Damage to vital organs e.g. liver
- Protrusion of intestines through gash

Pelvis, femurs:

Classic fractures from a high fall or car accident
Can lose up to half body's blood internally from abdomen fracture or open femur fracture

Anything else:

Damage to arms, rest of legs regarded as "extremity" trauma
Important to deal with it, but after "kill zone" injuries treated

What usually kills trauma victims?

Obstructed airway from unconsciousness
Damage to respiratory system
Internal bleeding
BEING KEPT ON-SCENE TOO LONG!

The Trauma Scene

First concern of the first aider is DANGER:

To him/herself
To bystanders
To the casualties

Typical on-scene dangers:

Traffic
Broken glass
Fire hazards (e.g. damaged cars)
Aggressive bystanders (especially with assault victims)
The casualties!

Remove or mitigate dangers before doing anything.

Next steps depend on situation:

Assert command of scene, or make yourself and your skills known to whoever has asserted command
If multiple patients, triage to determine who would get greatest benefit from first aid
Assess RESPONSIVENESS of casualties -- unconscious casualties are generally higher priority
SHOUT for help, and SEND people to SUMMON ambulance, police and (if needed) fire services
Treat casualties as always:
- Airway (but have regard to C-spine)
- Breathing
- Circulation

Treating Trauma Injuries

Clearing airway:

Usual "head tilt, chin lift" extends C-spine
Preferable is "jaw thrust" -- demonstrate on dummy
[Audience practices finding hand position for jaw thrust]
Note "chin lift" as alternative

Guarding the C-spine:

As ever, don't move casualty unless you really have to
Have a bystander hold casualty's head if possible
If casualty unconscious, use log roll or spinal recovery position (if you know how and have lots of people)
[Take audience through a log roll to show how hard it is]
But always, AIRWAY is the priority

Breathing problems:

"Trauma casualties are dying for oxygen"
Holes in the chest (e.g. from knife or bullet) should be blocked by a plastic dressing (e.g. plastic bag) sealed on three of the four sides
Be prepared to assist a casualty having breathing problems -- under 10 or over 30 breaths per minute means that not enough new air is getting into their lungs

Circulation:

Treat external bleeding as normal
Trauma casualties are almost always suffering from shock -- keep them warm and reassured
Unexplained shock in a casualty is a strong indicator of internal bleeding

Head injury / unconsciousness:

Guard the C-spine especially carefully
Make sure that their airway is clear
Get them into the recovery position
Be prepared to aid respiration
Oxygen is very important

General principles:

Definitive treatment is generally only available on the operating table -- call that ambulance early!
Bear in mind that you cannot see inside the casualty to determine what's wrong
Don't progress to the next stage (e.g. from B to C) until you've done all you can for the current stage

Example Scenario

You are driving along a country road late at night with two first aider friends in the car when you come to a sharp right-hand bend. A car has gone straight off the road and hit a tree. There is no fire or smoke. The front-seat passenger has come through the windscreen and is lying across the bonnet. You can see the driver plus two other people in the car. What do you do?

Managing The Scene

Priorities:

Danger:
- ensure that your car is parked safely with hazard flashers on
- ensure that you have torches and are wearing fluorescent clothing, if possible
- ensure that crashed car engine is turned off
- observe any broken glass or sharp metal, and cover or avoid it
Response:
- go around casualties checking their responsiveness
- if any don't respond, quickly open airway
Call for help. You need fire, police and ambulance. Use a mobile phone, or send one person in the car to the nearest dwelling. Tell them location, situation, and number of casualties.
Now priorities casualties. First, check those who are unresponsive

You determine that the front passenger is unresponsive, the driver moans unintelligibly, the passenger behind the driver is calm but says she is trapped by her feet, and the other passenger is in much pain from his abdomen but can talk. Who to treat first?

Talking casualties have airway and breathing OK
Moaning casualties are losing responsiveness and so airway is in danger
Fully unresponsive casualties come first

Treating The Casualties

You check the front passenger. They have come through the windscreen and are lying across the bonnet. There is obvious damage to their skull. You re-open their airway and check breathing. There is none. You give 2 rescue breaths and check carotid pulse. There is none.

Adult trauma casualties who arrest are generally unrecoverable even with a defib
Your effort would be better spent on salvageable casualties
Therefore, you turn to treat the driver.

The driver was wearing his seatbelt. The car had no airbag, and the steering wheel is deformed. He has obvious facial injuries including broken teeth. His breathing is very rapid. He moans when you talk loudly to him. He is sitting up in his seat.

Get your friend to hold his head steady (guarding C-spine)
Ensure that his Airway is clear
We already know about his Breathing
Check the Circulation -- his carotid pulse is weak and rapid
Nothing can be done for him other than to hold his head and ensure that he keeps breathing. Your friend can do this while you attend the other casualties.
You turn your attention to the passenger behind the driver since she is making less noise than the other passenger

The passenger behind the driver is a 40 year old woman. You ask her to stay where she is while you check her for injuries. Her breathing is slightly fast, as is her pulse. She is wearing a seatbelt (a shoulder and lap one.) She remembers a sudden bang, and her neck hurts. Her feet are trapped under the driver's seat, and one of her calves is bleeding profusely.

Try to control the bleeding as best you can
When your other friend returns, get him to hold her head and go to the fourth passenger.

This man was wearing a lap belt. His abdomen hurts and is tender to the touch. His breathing and pulse are faster than normal, and his skin is cool and wet. He doesn't think he's hurt anywhere else.

Skin signs tell all -- he's in shock
The lap-belt and tender abdomen indicate a bleed in the abdomen, a probable cause of the shock
The bleeding can only be controller in hospital

Handover

The first ambulance has arrived, and the paramedic asks you what's happened. You summarise.

Car went off the road suddenly, reason unknown
Front passenger through windscreen, pulseless
Driver restrained, moans to voice, rapid breathing
Rear right passenger restrained, neck pain, trapped by feet, profuse bleeding right calf
Read left passenger restrained by lap belt, tender abdomen and signs of shock

Recap And Review

Dealing with trauma can be very hard!
Apply DRSABC and you can't go far wrong
Never expect to get it right, just try to make as few mistakes as possible
Remember the Golden Hour and Platinum Ten Minutes

Where Next?

Courses covering trauma:

AFA -- OUFAU: Four days looking at advanced first aid, main focus on trauma-type injuries.
EMT -- USA and UK: Long and detailed course, basic trauma skills and use of equipment taught.
PHTLS -- USA and soon UK: Two days intensive focus on trauma skills for EMT and above, lots of practical sessions. Emphasis on short time on-scene.

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