Chapter1 scene size up

rp

1. International Trauma Life Support
for Emergency Care Providers
CHAPTER
eighth edition
International Trauma Life Support for Emergency Care Providers, Eighth Edition
John Campbell •Alabama Chapter, American College of Emergency Physicians
Scene Size-up
1

2. Copyright © 2016 by Pearson Education, Inc.
All Rights Reserved
Scene Size-Up

3. Copyright © 2016 by Pearson Education, Inc.
All Rights Reserved
Objectives
•Discuss the steps of Scene Size-up
•List two basic mechanisms of motion
injury
•Identify three collisions associated with
MVCs, and relate potential patient
injuries to deformity of vehicle, interior
structures, and body structures
•Name the five common forms of MVCs

4. Copyright © 2016 by Pearson Education, Inc.
All Rights Reserved
Overview
•Describe potential injuries associated
with proper and improper use of seat
restraints, headrests, and air bags in a
head-on collision
•Describe potential injuries from rear-
end collisions
•Describe the three assessment criteria
for falls, and relate them to anticipated
injuries

5. Copyright © 2016 by Pearson Education, Inc.
All Rights Reserved
Objectives
•Identify the two most common forms of
penetrating injury, and discuss
associated mechanisms and extent of
injuries
•Relate five injury mechanisms involved
in blast injuries and how they relate to
scene size-up and patient assessment

6. Copyright © 2016 by Pearson Education, Inc.
All Rights Reserved
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

7. Copyright © 2016 by Pearson Education, Inc.
All Rights Reserved
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 perform size-up can
jeopardize lives

8. Copyright © 2016 by Pearson Education, Inc.
All Rights Reserved
Scene Size-up
•First step in ITLS Primary Survey

9. Copyright © 2016 by Pearson Education, Inc.
All Rights Reserved
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

10. Copyright © 2016 by Pearson Education, Inc.
All Rights Reserved
Standard Precautions
•Exposure to blood or OPIM very likely
at a trauma scene
•Appropriate PPE must be worn
–Covered in more detail in Chapter 22

11. Copyright © 2016 by Pearson Education, Inc.
All Rights Reserved
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

12. Copyright © 2016 by Pearson Education, Inc.
All Rights Reserved
Initial Triage
•Total number of patients
–Call for backup
–Medical command
–Initiate MCI
protocols
–Any more
patients?
Courtesy of Bonnie Meneely, EMT-P

13. Copyright © 2016 by Pearson Education, Inc.
All Rights Reserved
Need for More
•Essential equipment
–Carry to scene for time efficiency
–Change gloves between patients
•Additional resources
–Call early
–Relay where to respond and any
dangers

14. Copyright © 2016 by Pearson Education, Inc.
All Rights Reserved
Mechanism of Injury
•Energy follows physics laws
–Injuries present in predictable patterns
•High-energy at risk of severe injury
–Consider injured until proven otherwise
•Type of MOI
–Generalized
–Focused

15. Copyright © 2016 by Pearson Education, Inc.
All Rights Reserved
Basic Motion Mechanisms
•Blunt injuries
–Rapid forward
deceleration
–Rapid vertical
deceleration
–Blunt instrument
energy transfer
•Penetrating
injuries
–Projectiles
–Knives
–Falls upon objects

16. Copyright © 2016 by Pearson Education, Inc.
All Rights Reserved
Motor-Vehicle Collisions
Each collision is three collisions:
Machine
Collision1 Body
Collision2 Organ
Collision3

17. Copyright © 2016 by Pearson Education, Inc.
All Rights Reserved
Other Collisions
•Secondary collisions
–Objects are
missiles
–Additional impacts
–Vehicle collides
with another object
–Other vehicles
collide with original
vehicle

18. Copyright © 2016 by Pearson Education, Inc.
All Rights Reserved
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?

19. Copyright © 2016 by Pearson Education, Inc.
All Rights Reserved
Common Collisions
•Common types
–Frontal-impact
–Lateral-impact
–Rear-impact
–Rollover
–Rotational
(©Jack Dagley Photography)

20. Copyright © 2016 by Pearson Education, Inc.
All Rights Reserved
Frontal-Impact Collision
•Windshield injuries
–Brain, soft-tissue
injury, cervical spine
•Steering wheel injuries
–Traumatic tattooing of
skin
•Dashboard injuries
–Face, brain, cervical
spine, pelvis, hip, knee
(Courtesy of Maria Dryfhout, Shutterstock )

21. Copyright © 2016 by Pearson Education, Inc.
All Rights Reserved
Lateral-Impact Collision
•Similar to frontal-
impact with lateral
energy
–Not easily predicted
–Consider organ damage
•Check impact side
–Head, neck, upper arm,
shoulder, thorax,
abdomen, pelvis, legs
(Photo courtesy of Anthony Cellitti, NREMT-P)

22. Copyright © 2016 by Pearson Education, Inc.
All Rights Reserved
Rear-Impact Collision
•Posterior displacement
–Rapid forward
deceleration also
possible
•Headrest position
–Hyperextension
injuries
•Damage back and front
–Deceleration injuries
(Courtesy of Bonnie Meneely, EMT-P)

23. Copyright © 2016 by Pearson Education, Inc.
All Rights Reserved
Rollover Collision
•Multiple impacts
–Multiple directions
–Multiple injuries
•Axial-loading injuries
–Spine injury
•Ejection
–Chance of death
increases 25 times
Courtesy of Bonnie Meneely, EMT-P
(Courtesy of Bonnie Meneely, EMT-P)

24. Copyright © 2016 by Pearson Education, Inc.
All Rights Reserved
Rotational Collision
•Head-on, lateral-
impact combination
–Converts forward
motion to spinning
motion
•Windshield,
dashboard, steering
wheel, side
–Same possible injuries
of both mechanisms
© Dedyukhin Dmitry / Shutterstock.com

25. Copyright © 2016 by Pearson Education, Inc.
All Rights Reserved
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”
–Lumbar spine
(Courtesy of Olivier Le Queinec, Shutterstock.com)

26. Copyright © 2016 by Pearson Education, Inc.
All Rights Reserved
Tractor Accidents
•50% of farm fatalities
–Side overturns 85%
Likely to throw clear
–Rear overturns 15%
Likely to entrap or
crush
•Common injuries
–Crush injuries
–Thermal or chemical burns
–Possible chemical exposure: insecticides
Courtesy of Roy Alson, MD

27. Copyright © 2016 by Pearson Education, Inc.
All Rights Reserved
Small-Vehicle Crashes
•Small vehicles
–Motorcycles
–All-terrain vehicles
–Personal watercraft
–Snowmobiles
•Factors
–Protective gear
–Additional impacts
© Orientaly / Shutterstock.com

28. Copyright © 2016 by Pearson Education, Inc.
All Rights Reserved
Pedestrian Injuries
•Mechanism
–Primary collision
–Additional impacts
•Common injuries
–Internal injuries and
fractures
Adult: bilateral leg,
knee
Children: pelvis, torso
Courtesy of Bonnie Meneely, EMT-P

29. Copyright © 2016 by Pearson Education, Inc.
All Rights Reserved
Falls
•Vertical deceleration
–Distance of fall
–Anatomy impact
–Surface struck
© Pearson

30. Copyright © 2016 by Pearson Education, Inc.
All Rights Reserved
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

31. Copyright © 2016 by Pearson Education, Inc.
All Rights Reserved
Penetrating Injuries
•Firearms
–Type of weapon
Low-velocity
High-velocity
–Caliber
Missile size
Bullet construction
Tumbling/yaw
–Distance traveled
Courtesy of Roy Alson, MD

32. Copyright © 2016 by Pearson Education, Inc.
All Rights Reserved
Penetrating Wounds
•Entry wound
–Smaller
–May be darkened,
burned
•Exit wound
–One, none, or many
–Larger
–May be ragged
•Do not label wounds as entrance or exit in
your notes.
(©Edward T. Dickinson, MD)

33. Copyright © 2016 by Pearson Education, Inc.
All Rights Reserved
Wound Ballistics
•Factors
–Missile velocity
–Missile size
–Missile deformity
–Missile design
–Tumbling and yaw
(Courtesy of Roy Alson, MD)

34. Copyright © 2016 by Pearson Education, Inc.
All Rights Reserved
Wound Ballistics
•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

35. Copyright © 2016 by Pearson Education, Inc.
All Rights Reserved
Blast Injuries
•Primary
–Initial air blast
•Secondary
–Material propelled
•Tertiary
–Impact on object
•Quaternary
–Dispersed hazardous material

36. Copyright © 2016 by Pearson Education, Inc.
All Rights Reserved

37. Copyright © 2016 by Pearson Education, Inc.
All Rights Reserved
Caution
Do not approach until
Scene Size-Up is complete!

38. Copyright © 2016 by Pearson Education, Inc.
All Rights Reserved
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