MASTER TEACHING NOTES
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Detailed Lesson Plan
Chapter 36
Multisystem Trauma and Trauma
in Special Patient Populations
120–140 minutes
Case Study Discussion
Teaching Tips
Discussion Questions
Class Activities
Media Links
Knowledge Application
Critical Thinking Discussion
Chapter 36 objectives can be found in an accompanying folder.
These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.
Minutes
Content Outline
I.
5
Master Teaching Notes
Introduction
Case Study Discussion
A. During this lesson, students will learn about special considerations an EMT
should have when caring for specific trauma populations.
B. Case Study
1. Present The Dispatch and Upon Arrival information from the chapter.
2. Discuss with students how they would proceed.
II. Multisystem Trauma—Golden Principles of Out-of-Hospital
30
Multisystem Trauma Care
A. Typically a patient is considered to have multisystem trauma when more
than one major body system is involved.
B. Multisystem trauma has a high incidence of morbidity and mortality.
C. Patients with multisystem trauma are at a greater risk of developing shock.
D. Golden principles
1. Ensure safety of the rescue personnel and the patient.
2. Determine additional resources needed.
3. Understand kinematics (mechanism of injury).
4. Identify and manage life threats.
5. Manage the airway while maintaining cervical spine stabilization.
6. Support ventilation and oxygenation.
7. Control external hemorrhage and treat for shock.
8. Perform a secondary assessment and obtain a medical history.
9. Splint musculoskeletal injuries and maintain spine immobilization. (Splint
en route for the unstable patient.)
10. Make transport decisions (rapid extrication, rapid export, and so on).
Remember that on-scene time is part of the platinum ten minutes and
the golden period between injury and definitive care at the hospital.
PREHOSPITAL EMERGENCY CARE, 9TH EDITION
DETAILED LESSON PLAN 36

Once you recognize that the patient is
pregnant, what special considerations
come to mind?
 What are some common mechanisms of
injury in pregnant patients?
Animation
Go to www.bradybooks.com and click on
the mykit link for Prehospital Emergency
Care, 9th edition to access an animation on
multisystem injuries in front-end collisions.
Discussion Questions

What is the relationship between
multisystem trauma and shock?
 Under what circumstances should you
request ALS or air medical support
when caring for a multisystem trauma
patient?
 What are the priorities when managing a
multisystem trauma patient?
 Why is it important to perform a
secondary assessment and obtain a
medical history from a trauma patient?
Knowledge Application
PAGE 1
Chapter 36 objectives can be found in an accompanying folder.
These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.
Minutes
Content Outline
Master Teaching Notes
Students should be able to apply
the principles of managing multisystem
trauma patients to a variety of lab
scenarios.
Class Activity
Have groups of students prepare
multisystem trauma scenarios to
demonstrate their understanding of the
effects of multisystem trauma. Review the
scenarios for accuracy during a break, and
use the scenarios for lab practice.
Teaching Tips

Allow ample opportunity for students to
apply the principles in lab scenarios.
 If weather and resources allow, have
students practice outdoors.
Critical Thinking Discussion
How can you develop the level of skill and
efficiency needed to care for critically
injured multisystem trauma patients?
III. Trauma in Special Patient Populations—Trauma in Pregnant
15
Discussion Questions
Patients
A. Trauma is the leading cause of death for pregnant women, and all women
who have suffered an injury should be evaluated by a physician in the
emergency room.
B. Anatomical and physiological considerations in the pregnant trauma patient
1. Total blood volume increases by 50 percent (shock).
2. Mother’s heart rate in third trimester increases by 10–15 bpm.
3. Uterus becomes more vascular.
4. Diaphragm elevates (tension pneumothorax).
5. Gastric motility increases (vomiting and aspiration).
6. Uterus grows and rises out of pelvis.
7. Renal blood flow increases.
8. Pelvic joints loosen and center of gravity changes (accidents and falls).
PREHOSPITAL EMERGENCY CARE, 9TH EDITION
DETAILED LESSON PLAN 36

What are common causes of injury in
pregnant patients?
 How does the anatomy and physiology
of pregnancy affect the response to
injuries?
PAGE 2
Chapter 36 objectives can be found in an accompanying folder.
These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.
Minutes
Content Outline
Master Teaching Notes
9. Fetal size in the third trimester can affect the patient’s venous return.
C. Assessment considerations in the pregnant trauma patient
1. More severe the injury to the mother, the greater the chances of fetal
injury.
2. Most common problem caused by maternal trauma is uterine
contractions that may progress into labor.
3. Types of problems from traumatic injury
a. Abruptio placentae—Separation of the placenta from the uterine
wall
b. Penetrating trauma—Stab wounds to the uterus provide 93 percent
morbidity to the fetus.
c. Motor vehicle crashes—Large percentage of maternal and traumatic
injuries
d. Fetal distress from hypoxia or hypovolemic shock
4. A pulseless woman in the third trimester should be transported to the
nearest appropriate medical facility for attempted resuscitation of the
mother and fetus unless instructed otherwise by medical direction.
D. Management considerations for the pregnant trauma patient
1. Most of the emergency care for a pregnant patient is the same as for
nonpregnant trauma patients and obstetric emergencies with a few
exceptions.
2. During full spine immobilization, be sure to tilt the long spineboard to the
left if the patient is in her third trimester or obviously pregnant.
3. Assess the patient’s breathing. Administer oxygen by nonrebreather
mask if breathing is adequate or bag-valve mask if breathing is
inadequate.
4. Assess the patient’s circulation and check for major bleeding. Absorb
blood flow from vaginal bleeding with a pad but do not pack the vagina.
5. Performa visual exam at the vaginal opening to assess for crowning or
bleeding.
6. Consider ALS intercept or air medical transport for major traumas
involving pregnant patients.
7. Best method to care for the fetus is by anticipating injuries and shock
and aggressively managing the mother.
PREHOSPITAL EMERGENCY CARE, 9TH EDITION
DETAILED LESSON PLAN 36
PAGE 3
Chapter 36 objectives can be found in an accompanying folder.
These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.
Minutes
Content Outline
Master Teaching Notes
IV. Trauma in Special Patient Populations—Trauma in Pediatric
15
Patients
A. Half of all deaths in children ages one to 14 are the result of trauma. (Motor
vehicle collision accounts for the majority of traumatic injuries.)
B. Findings that should prompt you to suspect abuse
1. Bruises or burns in unusual shapes and locations
2. Injury that doesn’t seem to correlate with the cause provided
3. More injuries than usual for a child that same age
4. Multiple injuries in various healing stages
C. Shaken-baby syndrome is one of many causes of brain injury.
D. Trauma involving a pediatric patient can be very stressful for the EMT,
patient’s family, and bystanders.
E. Anatomical and physiological considerations in the pediatric trauma patient
1. Traumatic forces are more widely distributed (multisystem trauma).
2. Child’s body surface area is greater than an adult’s (loses heat faster).
3. Pediatric patients have heavy heads and weak neck muscles (head and
spine injuries).
4. Internal organ placement makes the child more susceptible to injuries to
the spleen and liver.
5. Infants and children have greater chest wall flexibility.
6. Trauma to growth plates can impact the bones’ normal growth.
7. Children fatigue faster than adults.
F. Assessment considerations in the pediatric trauma patient
1. Pediatric Assessment Triangle can help you form a general impression.
2. Appearance—Refers to the child’s overall mental status, body position,
and muscle tone
3. Work of breathing—Visual effort of breathing and any audible sounds
associated with the patient’s respiration
4. Circulation—Patient’s skin color
5. Ensure patient airway, adequate ventilation, oxygenation, and
circulation.
6. Subtle changes in the pediatric trauma patient’s heart rate, blood
pressure, or perfusion status may indicate cardiorespiratory failure.
a. Assess brachial pulse in an infant.
b. Blood pressure readings are unreliable in children three years of age
or less.
c. Rely on other signs and symptoms such as skin color, temperature,
PREHOSPITAL EMERGENCY CARE, 9TH EDITION
DETAILED LESSON PLAN 36
Discussion Question
What are the differences in pediatric
patients that account for their greater
severity of injuries as compared to adults
exposed to similar forces?
Weblink
Go to www.bradybooks.com and click on
the mykit link for Prehospital Emergency
Care, 9th edition to access a web resource
on pediatric trauma considerations.
PAGE 4
Chapter 36 objectives can be found in an accompanying folder.
These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.
Minutes
Content Outline
Master Teaching Notes
condition, mental status, and capillary refill.
G. Management considerations for the pediatric trauma patient
1. Most of the management for a pediatric patient is the same as for adults
with a few exceptions.
2. During spine immobilization, pad beneath the child who is less than eight
years of age from the shoulders to the hips to prevent flexion of the
neck.
3. Open the airway and assess for any possible obstructions.
4. Assess the breathing rate and tidal volume.
5. Administer high-flow, high-concentration oxygen and monitor the
saturation via the SpO2 monitor.
6. Assess the circulation and control any external bleeding by direct
pressure.
7. Manage hypovolemia and shock as you would for an adult.
8. Prevent hypothermia.
9. Transport to an appropriate facility.
10. Continually reassess the pediatric trauma patient.
V. Trauma in Special Patient Populations—Trauma in Geriatric
15
Patients
A. Falls are the most common cause of injury in the elderly (often a result of a
medical condition). Second most common is motor vehicle collisions.
B. Most common injury is fracture.
C. Anatomical and physiological considerations in the geriatric trauma patient
1. Circulation changes can lead to the inability to maintain vital signs during
hemorrhage.
2. Shrinking brain can lead to a higher risk of cerebral bleeding following
head trauma.
3. Skeletal changes cause curvature of the upper spine.
4. Osteoporosis places the elderly patient at increased risk for fractures
and other injuries.
5. Other changes include decreased muscle size in the abdomen and
thinner skin.
D. Assessment considerations in the geriatric trauma patient
1. A decreased ability to respond to trauma, preexisting medical conditions,
and multiple medications all affect patient assessment and outcome.
2. Suspect a head injury for a patient with altered mental status.
3. Be mindful that the patient may wear dentures.
PREHOSPITAL EMERGENCY CARE, 9TH EDITION
DETAILED LESSON PLAN 36
Teaching Tip
Arrange a tour of a pediatric emergency
department or, if this is not possible,
consider a tour of the area of the ED in
which pediatric patients are treated.
Weblinks
Go to www.bradybooks.com and click on
the mykit link for Prehospital Emergency
Care, 9th edition to access web resources
on falls in nursing homes and geriatric
traumas.
Discussion Question
What are some things that affect the elderly
patient’s ability to compensate from
hemorrhage?
Teaching Tip
Arrange with an extended care facility to
have students assess elderly patients under
nursing supervision.
PAGE 5
Chapter 36 objectives can be found in an accompanying folder.
These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.
Minutes
Content Outline
Master Teaching Notes
4. Be prepared to suction and monitor the patient’s oxygenation using
pulse oximetry.
5. Patient’s who were hypertensive prior to an injury may have normal
blood pressure in shock.
E. Management considerations for the geriatric trauma patient
1. Management is very similar to that provided to other adults with a few
exceptions.
2. During spine immobilization, add padding around the spaces in the back
if necessary.
3. Open and maintain a clear airway; remember to suction.
4. Provide and support ventilation as needed.
5. Prevent hypothermia.
6. Splint fractures. Remember that traction splints are not used to treat hip
fractures.
7. Rapidly transport to the closest appropriate facility.
VI. Trauma in Special Patient Populations—Trauma in Cognitively
15
Impaired Patients
A. It can be difficult to recognize patients with cognitive impairment when you
begin your assessment.
B. Always maintain a high index of suspicion that your patient may have
suffered a traumatic head injury.
C. Anatomical and physiological considerations in the cognitively impaired
trauma patient—Considerations depend on the underlying cause of the
individual’s impairment.
D. Assessment considerations in the cognitively impaired trauma patient
1. Patients with cognitive impairments are not good at recalling or relating
their past medical history or events of the trauma. Address them with
respect and approach them as you would any other patient; however,
you may need to rely on others to provide information.
2. The traumatic event may make it even more difficult for the patient to
communicate and cooperate with you.
3. Remember that the patient’s pain perception may be altered.
4. The trauma assessment will provide the most pertinent information
about your patient.
5. Always maintain a high level of suspicion that your patient’s presenting
PREHOSPITAL EMERGENCY CARE, 9TH EDITION
DETAILED LESSON PLAN 36
Discussion Question
What are some guidelines to follow when
dealing with the cognitively impaired trauma
patient?
PAGE 6
Chapter 36 objectives can be found in an accompanying folder.
These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.
Minutes
Content Outline
Master Teaching Notes
signs and symptoms have resulted from trauma.
E. Management considerations for the cognitively impaired trauma patient
1. Involve the patient’s care givers in emergency treatment.
2. Err on the side of caution and do what is in the best interest of the
patient. Manage them as if they have a head injury.
Knowledge Application
Students should be able to apply the
information in this section to scenarios
involving assessment and management of
pregnant, pediatric, geriatric, and
cognitively impaired patients.
VII. Assessment-Based Approach: Multisystem Trauma and Trauma in
5
Special Patient Populations—Scene Size-Up
A. Ensure the scene is safe for you and others.
B. Look for a possible mechanism of injury and maintain a high index of
suspicion that more than one major body system may be affected in your
patient.
C. Identify if your patient belongs to any special populations and use your
knowledge about that population throughout your assessment.
D. Remember that unresponsiveness or altered mental status should always
suggest the possibility of head injury.
VIII. Assessment-Based Approach: Multisystem Trauma and Trauma in
5
Special Patient Populations—Primary Assessment
A. Suspect a cervical spine injury and maintain manual in-line spine
stabilization.
B. Assess your patient’s mental status using the AVPU mnemonic. You may
also use Glasgow Coma Scale and the Pediatric Assessment Triangle.
C. Establish an airway while holding in-line spine stabilization and ensure the
airway is free from obstructions.
D. Maintain the patient’s airway and assess the breathing rate and quality.
Provide oxygen via nonrebreather mask if breathing is adequate or provide
positive pressure ventilation with supplemental oxygen if breathing is
inadequate.
E. Assess the patient’s circulatory status and check the pulse as appropriate for
the special population (e.g. brachial pulse in infants)
Video Clip
Go to www.bradybooks.com and click on
the mykit link for Prehospital Emergency
Care, 9th edition to access a video on
immobilization considerations for pediatric
patients.
Animation
Go to www.bradybooks.com and click on
the mykit link for Prehospital Emergency
Care, 9th edition to access an animation on
differences between pediatric and adult
trauma patients.
IX. Assessment-Based Approach: Multisystem Trauma and Trauma in
10
Special Patient Populations—Secondary Assessment
A. Physical exam
1. Perform a rapid physical exam, and keep in mind that multiple systems
may be affected.
PREHOSPITAL EMERGENCY CARE, 9TH EDITION
DETAILED LESSON PLAN 36
PAGE 7
Chapter 36 objectives can be found in an accompanying folder.
These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.
Minutes
Content Outline
Master Teaching Notes
2. Remember that if your patient is pregnant, you have two patients to
consider.
B. Vital signs
1. Check and record vital signs every five minutes.
2. Normal vital signs are based on the patient’s age.
3. Remember that in the pregnant woman and elderly patient, you may
have what appears to be normal vital signs even though the patient is in
shock.
4. The slightest changes in a pediatric trauma patient’s vital signs many
indicate impending cardiorespiratory failure.
C. History
1. You may need to obtain information from others at the scene for
children, those with cognitive impairments, or those with an altered
mental status.
2. Questions to ask
a. When and how did the incident occur?
b. What is the patient’s chief complaint?
c. Does the patient have any signs or symptoms associated with the
trauma?
d. Is the patient pregnant? How far along is she? Is there any vaginal
bleeding or crowning?
e. How old is the patient?
f. Does the patient take any medications? Is the patient allergic to
anything?
g. What is the patient’s medical history? Is there a history of previous
trauma or cognitive impairment?
D. Signs and symptoms—Will vary based on the patient and the trauma
X. Assessment-Based Approach: Multisystem Trauma and Trauma in
5
Special Patient Populations—Emergency Medical Care
A. Take Standard Precautions.
B. Establish and maintain inline spine stabilization. Review relevant positioning
discussed earlier for a pregnant patient, a child less than eight years of age,
and an elderly patient.
C. Maintain a patient airway, and adequate breathing and oxygenation.
Maintain the SpO2 at 100% if the patient is pregnant.
D. Monitor the airway, breathing, pulse, and mental status for deterioration.
E. Control bleeding.
PREHOSPITAL EMERGENCY CARE, 9TH EDITION
DETAILED LESSON PLAN 36
Critical Thinking Discussion
How do the psychosocial developmental
stages of children of various ages affect
their responses to trauma and to treatment
by health care providers?
Discussion Questions

What are the priorities of care for
multisystem trauma patients?
 How is the management of pediatric
trauma patients different from that of
adults?
 What are some special considerations in
management of geriatric trauma
patients?
PAGE 8
Chapter 36 objectives can be found in an accompanying folder.
These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.
Minutes
Content Outline
Master Teaching Notes
F. Treat for shock.
G. Identify any other injuries and treat them appropriately.
H. Transport immediately. Be sure to notify the receiving facility and consider
the use of ALS intercept. Follow local protocol.
XI. Assessment-Based Approach: Multisystem Trauma and Trauma in
5
Special Patient Populations—Reassessment
A. Reassess during transport.
B. Pay close attention to the mental status, airway, breathing, and circulation of
these patients.
C. Repeat the vital signs every five minutes.
XII.
10
Follow-Up
Given a series of scenarios, students
should be able to assess and manage a
variety of patients from special populations.
Case Study Follow-Up Discussion
A. Answer student questions.
B. Case Study Follow-Up
1. Review the case study from the beginning of the chapter.
2. Remind students of some of the answers that were given to the
discussion questions.
3. Ask students if they would respond the same way after discussing the
chapter material. Follow up with questions to determine why students
would or would not change their answers.
C. Follow-Up Assignments
1. Review Chapter 36 Summary.
2. Complete Chapter 36 In Review questions.
3. Complete Chapter 36 Critical Thinking.
D. Assessments
1. Handouts
2. Chapter 36 quiz
PREHOSPITAL EMERGENCY CARE, 9TH EDITION
Knowledge Application
DETAILED LESSON PLAN 36

What are some possible injuries causing
Mrs. Miller’s signs of shock?
 What are your concerns for the fetus?
Class Activity
Alternatively, assign each question to a
group of students and give them several
minutes to generate answers to present to
the rest of the class for discussion.
Teaching Tips

Answers to In Review and Critical
Thinking questions are in the appendix
to the Instructor’s Wraparound Edition.
Advise students to review the questions
again as they study the chapter.
 The Instructor’s Resource Package
contains handouts that assess student
learning and reinforce important
information in each chapter. This can be
found under mykit at
www.bradybooks.com.
PAGE 9