Chapter 39
Special
Considerations
in Trauma
Copyright (c) The McGraw-Hill Companies, Inc. Permission required for reproduction or display.
39-1
Objectives
39-2
Trauma in Pregnancy
39-3
Mechanisms of Injury
• Effects of trauma on the fetus depend on:
– Length of the pregnancy (age of the fetus)
– Type and severity of trauma
– Severity of blood flow and oxygen
disruption to the uterus
39-4
Mechanisms of Injury
[Insert figure 39-10]
39-5
Mechanisms of Injury
• Falls
– Become more common
after the 20th week of
pregnancy
– Center of gravity shifts
as the size of the
abdomen increases
39-6
Mechanisms of Injury
• Intimate partner violence
• Physical abuse can result in the following
conditions:
– Blunt trauma to the abdomen
– Severe bleeding
– Uterine rupture
– Miscarriage
– Premature labor
– Premature rupture of the amniotic sac
39-7
Mechanisms of Injury
• Burns
– A thermal burn of more than 20% of the
mother’s body surface area increases the
risk of fetal death.
– In cases of electrical burns, the likelihood
of fetal death is high, even with a rather
low electrical current.
39-8
Anatomic and Physiologic Changes
• Diaphragm becomes elevated
• Resting respiratory rate increases
• Movement through the gastrointestinal tract
decreases
• Mother’s blood volume circulates through
the uterus every 8 to 11 minutes at term.
• Uterus begins to rise out of the pelvis and
becomes susceptible to injury.
39-9
Anatomic and Physiologic Changes
• Increased plasma volume
• Increased volume of red blood cells
• Heart rate gradually increases by as much as
10 to 15 beats/min
• During the first 6 months of pregnancy,
systolic blood pressure may drop 5-10 mm
Hg.
– Diastolic blood pressure may drop by 1015 mm Hg.
– During the last 3 months of pregnancy,
blood pressure returns to near normal. 39-10
Anatomic and Physiologic Changes
• Changes in vital signs during pregnancy can
make it difficult to detect shock
• When shock occurs:
– Blood is shunted from nonvital organs to
vital organs
– Uterine arteries constrict
– Decreased perfusion to the uterus
39-11
Patient Positioning
39-12
Abruptio Placentae
[Insert figure 39-8A]
39-13
Abruptio Placentae
[Insert figure 39-8B]
39-14
Uterine Rupture
• Tearing (rupture) of the uterus
• Possible causes:
– Strong labor for a long period
• Most common cause
– Abdominal trauma
• Severe fall
• Sudden stop in a motor vehicle collision
39-15
Restraint Systems
• Women should use automobile restraints
while pregnant.
• Correct seat belt use can significantly reduce
both maternal and fetal injury.
39-16
Penetrating Trauma
• Gunshot wounds are more
common than knife
wounds.
• Maternal outcome is
usually favorable
• Fetal death rate is high
39-17
Cardiac Arrest
• Diaphragm elevated during pregnancy
– May be necessary to ventilate using less
volume
• Chest compressions should be performed
higher on the sternum
– Slightly above the center of the sternum
• If the patient is 20 weeks pregnant or more,
– Perform chest compressions with the
patient tilted 15° to 30° to the left
39-18
Assessment of the
Pregnant Trauma Patient
39-19
Patient Assessment
• Scene size-up
• Evaluate mechanism of injury
• Remember that you have two patients to
consider – the mother and the fetus.
• Assess ABCs while maintaining spinal
stabilization
• Never withhold oxygen from a pregnant
trauma patient.
39-20
Patient Assessment
• Short on-scene time
• Rapid transport to trauma center
• ALS intercept or air medical resources may
be needed
39-21
Patient Assessment
• (If the mechanism of injury involved a motor
vehicle crash) Were you wearing a seatbelt?
– Lap belt and shoulder strap?
• Did you feel the baby move before the
trauma? After the trauma?
• Did you experience any direct trauma to your
abdomen?
• Are you experiencing any contractions?
• Are you experiencing any vaginal bleeding?
39-22
Patient Assessment
• Did your water break?
– If yes, what color was it?
• When was your last menstrual period?
• What is your due date?
• Have you received any prenatal care?
• Is this your first pregnancy? How many
babies are expected?
• Do you have any medical problems
(diabetes, high blood pressure)?
39-23
Emergency Care
39-24
Emergency Care
• Put on appropriate PPE. Keep on-scene time
to a minimum.
• If spinal injury is suspected, immobilize the
patient to a long backboard.
– Tilt the board to the left if the patient is 20
weeks pregnant or more.
• Establish and maintain an open airway.
• Administer 100% oxygen.
• Continue monitoring oxygenation using
pulse oximetry.
• Control external bleeding.
39-25
Emergency Care
• Generally, the pregnant trauma patient who
has a heart rate of more than 110 beats/min,
chest or abdominal pain, loss of
consciousness, or is in her third-trimester of
pregnancy should be transported to a trauma
center.
• Follow your local protocols.
• Reassess at least every 5 minutes en route.
39-26
Pediatric Trauma
39-27
Mechanisms of Injury
– Motor vehicle-related injuries
– Car-pedestrian incidents
39-28
Mechanisms of Injury
•
•
•
•
•
•
•
Bicycle-related injuries
Drowning
Fire-related injuries
Penetrating trauma
Falls
Sports-related injuries
Abuse and neglect
39-29
Anatomic and Physiologic Changes
• The head is large and heavy compared with
body size
• Blood vessels of the face and scalp bleed
easily
• When the head is struck, it jars the brain
– Brain bounces back and forth
– Causes multiple bruised and injured areas
39-30
Anatomic and Physiologic Changes
• Shaken baby syndrome
– Also called abusive head trauma
– May cause brain trauma
– Can lead to severe brain damage or death
– Never shake or jiggle an infant or child.
39-31
Anatomic and Physiologic Changes
• Chest
– Soft, pliable ribs
– May have significant injuries without
external signs
39-32
Anatomic and Physiologic Changes
• Abdomen
– More common site of injury than in adults
– Often a source of hidden injury
39-33
Anatomic and Physiologic Changes
• Pelvic fractures
– Uncommon in children
• Extremity trauma
– Common in children
– Managed in the same way as for adults
39-34
Patient Assessment
• Scene size-up
• Evaluate the mechanism of injury
• Put on appropriate PPE
• Comfort, calm, and reassure the patient
• Keep on-scene time to a minimum.
• If major trauma:
– Request ALS personnel to the scene or
consider an ALS intercept
– Do not delay transport for ALS arrival.
39-35
Patient Assessment
• Perform a primary survey
• Assume that any patient who has an injury
above the collarbones has a spinal injury and
immobilize accordingly.
• Provide padding under the torso of infants
and young children to maintain the cervical
spine in a neutral position.
39-36
Patient Assessment
• Airway
– Keep the airway open and clear of
secretions
– Gurgling or stridor may indicate an upper
airway obstruction.
– Vomiting is common
– Keep young infant’s nasal passages clear
– Use jaw thrust maneuver to open airway
39-37
Patient Assessment
• Carefully assess rate and depth of breathing.
• Rates that are too fast or slow can indicate
respiratory failure.
• Look for signs of increased work of
breathing.
• Give supplemental oxygen to all pediatric
trauma patients.
• A pulse oximeter should be routinely used
and continuously monitored in any trauma
patient.
39-38
Patient Assessment
• Control obvious bleeding if present.
• Check for signs of shock
– Mental status
– Heart rate
– Peripheral versus central pulse quality
– Skin color
– Capillary refill time
• If the child is 6 years of age or younger
39-39
Patient Assessment
• Assess the child’s mental status
– AVPU scale
– Glasgow Coma Scale
• Obtain patient’s vital signs
– Vary by age
– A slow pulse rate indicates hypoxia until
proven otherwise.
– Normal vital signs in an injured child can
be deceiving.
39-40
Patient Assessment
• Obtain a SAMPLE history.
• Remember to talk to your patient.
• Keep the family informed.
39-41
Emergency Care
• Put on appropriate PPE.
• Keep on-scene time to a minimum.
• Request an early response of ALS personnel
to the scene or consider an ALS intercept.
• If spinal injury is suspected, maintain manual
in-line stabilization until the patient is
secured to a long backboard
• Establish and maintain an open airway.
• Give oxygen.
39-42
Emergency Care
• Promptly seal an open chest wound with an
airtight dressing.
• Control external bleeding.
• If signs of shock are present or if internal
bleeding is suspected, treat for shock. Keep
the patient warm.
• Do not remove penetrating objects.
• Manage avulsed or amputated parts as other
soft tissue injuries.
• Reassess at least every 5 minutes.
39-43
Trauma in Older Adults
39-44
Mechanisms of Injury
• Falls are the most common cause of injury in
older adults.
• Most falls occur at home and are low-level
falls (falls from a standing height).
• Injuries to the head, pelvis, and lower
extremities are common.
39-45
Mechanisms of Injury
• Motor vehicle crashes
– Injuries similar to those of younger
patients
– Increased incidence of sternal fractures
from seatbelts.
• Pedestrian versus vehicle incidents
– High death rate, usually from a severe
head or major vascular injury
39-46
Mechanisms of Injury
• Burn injuries
– Death rate in older adults is high
– Any older adult who has experienced a
burn injury should be triaged to a burn
center, if available in your area.
39-47
Possible Signs of Elder Abuse
• Bruises, black eyes, welts, lacerations, rope
marks
• Bone fractures, skull fractures
• Untreated injuries in various stages of
healing
• Older adult’s report of being hit, slapped
• Physical signs of punishment
• Signs of being restrained
• Older adult’s sudden change in behavior
• Caregiver’s refusal to allow visitors to see an
older adult alone
39-48
Anatomic and Physiologic Changes
• Higher risk of cerebral bleeding following
head trauma
• Increased risk of falls
• Reduced blood flow to organs
• A “normal” blood pressure in an older adult
who is usually hypertensive may actually
represent hypotension.
39-49
Anatomic and Physiologic Changes
• Medications may include:
– Cardiac drugs
– Diuretics (“water pills”)
– Sedatives, antidepressants
– Anticoagulants
39-50
Patient Assessment
• Scene size-up
• Evaluate the mechanism of injury
• Put on appropriate PPE
• Scan your surroundings
39-51
Patient Assessment
• Remove dentures if they do not fit well.
• Cough reflex may be diminished
– Suction as needed
• Use a pulse oximeter to monitor
oxygenation.
• Older adult’s pulse may be irregular
• Slower than expected heart rate may be
caused by prescribed cardiac medications.
39-52
Patient Assessment
• Assess level of consciousness using the
AVPU scale
• Follow the AVPU assessment using the
Glasgow Coma Scale.
• Obtain a Revised Trauma Score and
document your findings.
39-53
Patient Assessment
• Expose the patient as necessary.
– Respect the patient’s modesty.
– Keep him covered as much as possible to
maintain warmth.
• Treat any life-threatening injuries before
proceeding to the secondary survey.
• Generally, it is a good idea to do a head-totoe examination of any older adult who has
been injured.
39-54
Emergency Care
•
•
•
•
•
•
Put on appropriate PPE.
Keep on-scene time to a minimum.
Cervical spine precautions
Establish and maintain an open airway.
Administer supplemental oxygen
Continue monitoring oxygenation using
pulse oximetry.
• Control external bleeding.
39-55
Emergency Care
• Do not remove penetrating objects.
• Manage avulsed or amputated parts as other
soft tissue injuries.
• Do not touch protruding organs.
• Keep the patient warm.
• Reassess at least every 5 minutes.
39-56
Trauma in the
Cognitively Impaired Patient
39-57
Cognitively Impaired Patient
• Cognition
– Mental functioning
• Cognitive impairment
– A change in a person’s mental functioning
caused by an injury or disease process
– Affects a person’s ability to process, plan,
reason, learn, understand, and remember
information
39-58
Cognitively Impaired Patient
• Examples of conditions that may involve
cognitive impairment
– Alzheimer’s disease
– Vascular dementia
– Down’s syndrome
– Autistic disorders
– Traumatic brain injury
– History of a stroke
39-59
Cognitively Impaired Patient
• Signs and symptoms vary
– Patient may be confused or easily agitated
– Some patients bang their heads.
– Others injure themselves or are unafraid of
danger, making them more susceptible to
trauma.
– Some patients have difficulty
communicating and interacting with other
people.
39-60
Cognitively Impaired Patient
• The patient may be an unreliable historian
– Past medical history
– Events of trauma
• Adult patient may not be legally able to
consent to treatment
39-61
Cognitively Impaired Patient
• Can you tell me why you called us today?
• What is the patient’s name?
• How does the patient normally
communicate?
• How aware is he of the environment?
• What are his usual motor skills and level of
activity?
• What is his usual sleep pattern and appetite?
• Does he have any problems with his sight?
• Does he have any problems with his
39-62
hearing?
Cognitively Impaired Patient
• Generally, it is helpful to have a caregiver
present during the physical exam.
• Ask for the patient’s name and use it when
providing patient care.
• Ask the patient’s family or caregiver to
describe the patient’s normal mental status.
• Attempt to take the patient’s vital signs when
he is calm.
39-63
Questions?
39-64