Ivano-Frankivsk National Medical University

Department of disaster and military medicine

Emergency and urgent medical care

LECTURE
"Emergency medical care for trauma at
the pre-hospital stage"
lecturer
Anna Ovchar
Ivano-Frankivsk - 2023
Plane of lecture
1. Primary and injuries.
secondary trauma 9. Burns.
assessment. 10. Frostbites.
2. Tactical medicine. 11. Hypothermia.
3. Thoracic trauma. 12. Blast injury.
4. Head trauma. 13. Compartment
5. Abdominal trauma. syndrome.
6. Shock. Types of shock 14. Crush syndrome.
in trauma patients.
7. Pelvic injury.
8. Musculoskeletal
Purpose of lecture

 Concise approach to the care of a trauma patient

by use international protocols PHTLS and
ATLS.
 Master how to assess a patient’s condition
(ABCDE, CABCDE, MARCH), resuscitate and
stabilize trauma victim at the prehospital stage.
The Global status report
on road safety 2018, Epidemiology
launched by WHO in
December 2018,
highlights that the
number of annual road
traffic deaths has
reached 1.35 million.

Major injury is the

sixth leading cause of
death worldwide.
Among those under 35
years of age, it is the
leading cause of death
and disability.

Road traffic injuries

are now the leading
killer of people
aged 5-29 years.
Injury: Scale of the Global Problem
• 5 million deaths/year
• 9% of worlds deaths
• 1.7 times the number of
fatalities that result from
HIV/AIDS, TB and malaria
combined

Every six seconds someone in the world dies as

a result of an injury!
Trauma Team
Scene size-up
1. Hazards [Link] type and severity of
– Power lines, gas, animals, injuries
people [Link] Assessment and Rapid
2. PPE Trauma
3. Number of patients Survey
– Establish command – Less than 2 minutes
–Additional resources
Follow these guidelines when arriving
on an emergency scene:
 Take time to evaluate the scene and recognize existing and
potential dangers.
 Never attempt to do anything you are not trained to do.
 Get the help you need to ensure your safety, the safety of
those assisting you and, to the extent possible, the patient.
 Discourage other people from entering an area that
appears unsafe.
 Never move patients until you treat and stabilize them
unless immediate danger threatens you or the patient.
 If it is necessary to move a patient, do so safely and
quickly.
Initial Assessment
 General impression:
- Obvious major injuries or bleeding
- Immediately control life-threatening bleeding
- Approximate age, sex, weight
- General appearance
- Position of patient body and surroundings
-Patient activity
 ABCDE
– A Airway and c-spine protection
– B Breathing and ventilation
– C Circulation with hemorrhage control
– D Disability/Neurologic status
– E Exposure/Environmental control
Obvious hemorrhage can change order of ABC to
Initial Assessment
(Primary Survey)
TCCC
 They were offered new approaches and
started a new trend - Tactical Combat
Casualty Care (TCCC) 15 December 2021
year
TCCC
 The first recommendation, which were
TCCC, focused on the treatment of the three
main causes of deaths in preventive injuries
that occur on the battlefield:
 - Massive bleeding from the wounds of the
extremities;
 - Tension pneumothorax;

- Obstruction of the upper airways.

Algorithm MARCH
 The MARCH algorithm is synonymous with
Tactical Combat Casualty Care (TCCC).
 It is a simple acronym for remembering the
necessary steps in priority for saving lives in
combat.
 M-massive hemorrhage,
 A-airway,
 R-respiratory,
 C-circulation,
 H-hypothermia.
MARCH
 M- Massive Hemorrhage: stop life threatening bleeding.
– Tourniquet.
 A- Airway
– Head tilt chin lift, jaw thrust, nasopharyngeal (done by first
responders).
– Cricothyroidotomy, intubation (done by the medic).
 R- Respiration: seal holes in chest, relieve tension
pneumothorax.
– Chest seals, needle decompression.
 C- Circulation: assess and treat for shock.
– IV/IO access, blood products better than clear fluids.
 H- Hypothermia:
– Treat additional wounds as you find them.
– Prevent hypothermia.
– Give pain medication.
– Give antibiotics.
Initial Assessment
(Primary Survey)
CABCDE stands for:
 Catastrophic bleeding: check for massive bleeding and stop
it.
 Airway: check for and correct any obstruction to movement
of air into the lungs.
 Breathing: ensure adequate movement of air into the lungs.
 Circulation: evaluate whether there is enough oxygen being
delivered to the tissues; check for signs of life-threatening
bleeding.
 Disability: assess and protect the brain and spine. (Always
suspect head and spine injury in a trauma patient with
altered mental status.)
 Exposure: identify all injuries and any environmental
threats, and prevent hypothermia.
Signs of catastrophic bleeding
A- Airway
Look for:
blood, vomit, tongue or objects obstructing the
airway
burned nasal hairs or soot around the nose or mouth
head or neck trauma
neck haematoma (bleeding under the skin)
altered mental status, as this can affect the patient’s
ability to protect their airway.
Listen for abnormal airway sounds (such as gurgling,
snoring, stridor or noisy breathing).
Airway Interventions
Supplemental oxygen
Suction
Chin lift/jaw thrust
Oral/nasal airways
Definitive airways
RSI for agitated patients with c-spine immobilization
ETI for comatose patients (GCS<8)
Airway Devices
 Laryngeal Mask Airway (LMA) and I-Gel LMA
 Laryngeal Tube (LTA)
 Endotracheal intubation
 Surgical airway (Cricothyroidotomy)
Assume c-spine injury in patients with
multisystem trauma
B- Breathing
Look for:
increased work of breathing
abnormal chest wall movement, which may indicate flail chest
tracheal shift
sucking chest wound
cyanosis (blue-grey colour of the skin) around the lips and fingertips
abrasion, bruising or other signs of injury to the chest
circumferential burns (burns that go all the way around a body part) to
the chest or abdomen.
Listen for:
absent or decreased breath sounds
dull sounds or hyperresonance with percussion.
Feel for crepitus (cracking and popping as you press on the skin).
Breathing Interventions

Ventilate with 100% oxygen

Needle decompression if tension
pneumothorax suspected
Chest tubes for pneumothorax /
hemothorax
Occlusive dressing to sucking
chest wound
C- Circulation
Hemorrhagic shock should be assumed in any hypotensive trauma
patient
Look for:
capillary refill takes longer than three
seconds Common sources of
pale extremities serious bleeding are:
• chest injuries
distended neck veins • abdominal injuries
external and internal bleeding. • pelvic fractures
• femur fractures
Feel for: • amputations or large
cold extremities external wounds
weak pulse or tachycardia (fast heart • burns (note size and
depth).
rate).
Circulation Interventions
Cardiac monitor
Apply pressure to sites of external hemorrhage
Establish IV access
2 large bore IVs
Central lines if indicated
Cardiac tamponade decompression if indicated
Volume resuscitation
Have blood ready if needed
Level One infusers available
Foley catheter to monitor resuscitation
D - Disability
Look for:
confusion, lethargy or agitation
seizures/convulsions
unequal or poorly reactive pupils
deformities of the skull
blood or fluid from the ear or nose.

Check:
AVPU scale (alert, verbal, pain, unresponsive) or Glasgow Coma
Scale (GCS) – the AVPU scale is simpler to use for children
movement and sensation in all extremities
blood glucose level if the patient is confused or unconscious.
AVPU
GCS
EYE VERBAL MOTOR

Spontaneous 4 Oriented 5 Obeys 6

Verbal 3 Confused 4 Localizes 5

Pain 2 Words 3 Flexion 4

None 1 Sounds 2 Decorticate 3

None 1 Decerebrate 2
None 1
Disability Interventions

Spinal cord injury

High dose steroids if within 8 hours

ICP monitor
Elevated ICP
Head of elevated
Mannitol
Hyperventilation
Emergent decompression
E- Exposure
 Remove all clothing
Examine for other signs of injury
Injuries cannot be diagnosed until seen by provider
 Logroll the patient to examine patient’s back
Maintain cervical spinal immobilization
Palpate along thoracic and lumbar spine
Minimum of 3 people, often more providers required
 Avoid hypothermia
Apply warm blankets after removing clothes
Hypothermia = Coagulopathy (Increases risk of
hemorrhage)
Always Inspect the Back
Secondary Survey
The secondary survey is a head-to-toe
evaluation of the trauma patient - that is, a
complete history and physical
examination, including reassessment of all
vital signs.

SAMPLE history
Physical exam from head to toe,
including rectal exam (DCAP-
BLS-TIC)
Brief Targeted History
SECONDARY SURVEY
 Head Exam  Chest Exam
–Scalp, eyes, ears –Clavicles, ribs
–Soft tissues –Breath, heart sounds
 Neck Exam  Abdominal Exam

–Penetrating injuries –Penetrating injury

–Swelling or crepitus –Blunt injury: nasogastric tube
 Neurological Exam –Rectal exam
–Glasgow Coma Score –Urinary catheter
–Motor examination  Pelvis and Limbs

–Sensory examination –Fractures

–Reflexes –Pulses
–Lacerations, ecchymosis
Detailed exam (DCAP-BLS-TIC)
HINTS and TIPS

What are the names of

these signs?
Seatbelt Sign
Thoracic trauma
Thoracic injury causes 20–25% of trauma deaths
Mechanism of injury and
classification
 Blunt
– Direct compression
§ Fracture of solid organs
§ Blowout of hollow organs
–Deceleration forces
§ Shearing of organs and blood vessels
 Penetrating

– Direct trauma to organ and vasculature

– Energy transmitted from mass and velocity
“Deadly Dozen”
of thoracic trauma
1. Airway obstruction 7. Myocardial contusion
2. Flail chest 8. Traumatic aortic rupture
3. Open pneumothorax 9. Tracheobronchial injury
4. Massive hemothorax [Link] tears
5. Tension pneumothorax [Link] contusion
6. Cardiac tamponade [Link] injuries
Flail Chest
A flail segment results when 2 or more adjacent
ribs are fractured in two or more places
Signs and symptoms
 Shortness of breath
 Chest pain
 Cyanosis
 Asymmetrical movement
 Chest wall contusion
 Tenderness, instability,
crepitation (TIC)
 Breath sounds abnormal
Flail chest management

 High-flow oxygen
 Assist ventilation
 Possible intubation
 Stabilize flail segment
 Painkillers (promedol, morphine, ketamine ets)
 Transportation to the hospital
 Monitor for Hemothorax and Pneumothorax
Open chest wound
Large defects of the chest wall The clinical signs and
that remain open can result in symptoms:
an open pneumothorax, or
 Pain
sucking chest wound.
 Difficulty breathing
 Tachypnea
 Decreased breath
sounds on the affected
side
 Noisy movement of air
through the chest wall
injury.
Open chest wound management
Initial management of an open pneumothorax is
accomplished by promptly closing the defect with a
sterile occlusive dressing.
The dressing should be large enough to overlap
the wound’s edges and then taped securely on three
sides in order to provide a flutter-type valve effect.

An improvised occlusive dressing may be the standard of care

Open pneumothorax treatment
A commercial occlusive dressing:
Asherman Chest Seal
HALO Chest Sea

An Asherman Chest
Seal, which is vented

A HALO Chest Seal,

which is vented
TENSION PNEUMOTHORAX
A tension pneumothorax develops when a “one-way valve”
air leak occurs from the lung or through the chest wall.
Tension pneumothorax is characterized by some or all of
the following signs and symptoms:
Chest pain
Air hunger
Respiratory distress
Tachycardia
Hypotension
Hyperresonance if percussed
Tracheal deviation
Unilateral absence of breath sounds
Neck vein distention
Cyanosis (late manifestation)
Tension Pneumothorax

How do you treat this?

Tension pneumothorax
management

 High flow oxygen

 Aseptic skin preparation
 Insert a large bore needle over rib
 Immediate transportation to the
hospital
Needle Decompression
Two acceptable sites:
Lateral site
–The 5th intercostal space
(ICS) in the anterior
axillary line (AAL)
or
 Anterior site
– The 2nd ICS in the mid-
clavicular line (MCL)
Needle Decompression
Regardless of the method
chosen, decompression
should be performed with a
large-bore (10- to 16-
gauge) IV needle that is
at least 8 cm (3.5 inches) in
length.
Recent evidence suggests that a 5 cm needle will reach the
pleural space >50% of the time,
whereas an 8 cm needle will reach the pleural space >90% of
the time.
CAUTION!

• At the anterior site, the heart and great vessels are nearby.
• Never insert the needle medial to the nipple line.
• Do not point the needle towards the heart.

The two needles circled are TOO MEDIAL!

Anterior insertion site
needle set stabilized between
thumb and middle finger

mid-clavicular line

needle set penetrating skin

and identifying 3rd rib
55

Perpendicular to chest wall

Lateral insertion site

insertion site
identification

r-a x i l l ary
o
anteri i l l a ry
- a x
4th ICS mi d
- a x i l lary
io r
poster
one mark & cleans site
safe z area over 4th & 5th
intercostal spaces
anterior axillary line

5th ICS
identify 4th or 5th intercostal space
anterior axillary line (or between anterior and mid axillary lines)
site verification
and framing

site reverification 4th ICS

insertion site is
superior to
targeted rib

lateral insertion 5th ICS

4th ICS

needle set stabilization

improves precision
placement and
depth control
5th ICS

lateral insertion
insertion site
framing

needle set must remain

perpendicular to chest wall
during insertion

insertion site is
superior to targeted rib hand stabilization

needle set stabilization

with finger tip depth control
59

lateral insertion
Hemothorax

Hemothorax occurs when blood enters the

pleural space. This space can accommodate a
large volume of blood (2,500 to 3,000 ml).
Signs of hemothorax
The bleeding may come from the chest wall
musculature, intercostal vessels, lung parenchyma,
pulmonary vessels, or great vessels of the chest.

 Anxiety and confusion

 Chest pain
 Neck veins flat (hypovolemia)
 Breath sounds decreased or absent
 Dull songs if percussed
 Shock signs (tachycardia, tachypnea, confusion,
pallor, and hypotension)
Hemothorax management
 High-flow oxygen,
ventilation support
 Load-and-go
(Hospitalization)
 Treat for shock
 Fluid administration
 Monitor patient for tension
hemopneumothorax
Impaled objects

 Do not remove
 Stabilize the object with
bandage
 Monitor for:
• Tension pneumothorax
• Hemothorax
• Cardiac tamponade
Head trauma
Head injuries can be closed or open
Closed injuries occur when the
cranium remains intact. Signs
and symptoms of closed head
injuries can present hours and
even days after the injury
occurs.
Open injuries occur
when the cranium and
overlying soft tissue
are broken, exposing
the meninges or
brain.
Concussion
A concussion occurs when a blow to the head causes minor and
temporary damage to the brain. The injury may be:
minor that it does not cause a loss of consciousness;
mild, causing a headache after a brief loss of consciousness;
severe, causing a prolonged loss of consciousness and abnormal vital
signs, sometimes short-term memory lost.
Contusion
A contusion occurs when the force is great enough
to damage the capillaries on the surface of or
deep within the brain. This results in swelling of
the brain tissue. As the swelling increases, the
brain tissues lose their ability to function
normally.
Hemorrhage (bleeding)
If the mechanism of injury
is severe enough, it can
cause rupture of blood
vessels in the brain. In a
closed head injury, the
blood has no opening
from which to drain. The
blood builds up inside the
skull, presses on the
brain, and may affect or
impair normal brain
function.
Hemorrhage
Intracranial hemorrhage:
– Epidural (between skull
and dura mater
– Subdural (between dura
and arachnoid)
– Intracerebral (directly
into brain tissue)
–Subarachnoid (between
the arachnoid and pia
mater)
Epidural Hematoma
Epidural hematomas are relatively uncommon, occurring
in about 0.5% of TBI patients and 9% of patients with TBI
who are comatose.
 Arterial bleed (middle meningeal artery)

§ Temporal fracture common

§ Onset: minutes to hours
 Level of consciousness

§ Initial loss of consciousness

§ “Lucid interval” follows
 Associated symptoms

§ Pupils are unequal in size (anisocoria), fixed pupil, signs

of increasing ICP, unconsciousness, contralateral
paralysis, death.
Epidural Hematoma
Subdural Hematoma
Subdural hematomas are more common than epidural hematomas,
occurring in approximately 30% of patients with severe brain injuries.
The bridging veins tear and bleed in a subdural hematoma. History
may be chronic (weeks) or subacute (days) as the bleed is slow due to the
low pressure in the venous system.
 Venous bleed
§ Onset: hours to days
 Level of consciousness

§ Fluctuations (as defined by markers like the Glasgow coma scale)

 Associated symptoms

§ Headache, nausea and vomiting, dizziness.

§ Focal neurologic signs (mydriasis, hemiparesis ets.)
 High-risk

§ Alcoholics, elderly, taking anticoagulants

Subdural Hematoma
Intracerebral hemorrhage
Intracerebral hemorrhage (bleeding into the brain tissue)
is the second most common cause of stroke (15-30% of
strokes) and the most deadly.
 Arterial or venous
 Level of consciousness

§ Alterations common
 Associated symptoms

§ Varies with region and degree (weakness/numbness in

face, arm or leg (usually on one side),vision loss ets.)
§ Headache and vomiting
§Seizures
Head injury management
1. Perform a primary assessment, and ensure the ABC are intact. If
the patient is unresponsive, open the airway! (advanced
management)
2. If necessary, provide rescue breaths.
3. Control any obvious bleeding. Be careful to apply only enough
pressure to stop the bleeding.
4. Keep the patient still and lying flat. Maintain manual
stabilization of the head and neck.
5. Administer supplemental oxygen.
6. Have suction prepared in case the person vomits..
7. Monitor vital signs, including mental status.
[Link] sedation if agitated or aggressive, anticonvulsant.
[Link] access avoid hypotension.
[Link] if cerebral herniation.
SPINE INJURIES
A spinal cord injury causes loss of muscle function or sensation. The
effects of the injury occur in the parts of the body connected to the
spinal cord below the level of the damage.
Abdominal Trauma

Injuries to the abdominal and

pelvic areas are susceptible to the
falls, contact sports, vehicle
collisions, and blasts are common
causes of blunt injuries.
Open abdominal injuries are
often the result of a penetrating
Abdominal Trauma
Look for distension, tenderness,
seatbelt marks, penetrating trauma,
retroperitoneal ecchymosis
Be suspicious of free fluid without
evidence of solid organ injury
Primary Survey: Abdomen
 –Deformities
 – Contusions
 –Abrasions
 – Punctures
 – Evisceration
 – Distension
 – Tenderness
BLUNT TRAUMA
Numerous mechanisms lead to the compression and shear
forces that may damage abdominal organs.
 Liver (45%) and spleen (55%) injury most common
 Evidence of injury:

– Often no or minimal external evidence

–Significant blood volume concealed in regions
– Seat-belt sign: 25% intra-abdominal
 – Pain or tenderness (often no pain or overshadowed by
other pain)
PENETRATING TRAUMA
Most penetrating trauma in the civilian setting results from
stab wounds and gunshot wounds from handguns.
 Stab wounds the most commonly involve
liver (40%), small bowel (30%),
diaphragm (20%), and colon (15%).
 Gunshot wounds may cause additional
intraabdominal injuries based upon the
trajectory, cavitation effect, and possible
bullet fragmentation. Gunshot wounds
most commonly involve the small bowel
(50%), colon (40%), liver (30%), and
abdominal vascular structures (25%).
Abdominal Evisceration
An evisceration common type of open
abdominal injury occurs when the abdominal
wall is penetrated by a sharp object and the
contents of the abdomen are allowed to spill
out. Never attempt to place spilled abdominal
contents back into an open wound. This could
cause many complications as well as introduce
infection into the wound.
Care for a person with an abdominal evisceration should
include the following:
1. Expose the wound and any organs that
may have spilled out by removing or cutting
away clothing.
2. Position the patient on his back. If no
spine injury is suspected, have the patient
bend his knees. This will put less tension on the
abdominal muscles.
3. Place a large sterile dressing soaked with
sterile water or saline over the exposed
abdominal contents.
4. Cover the moist dressing with plastic. This
will help contain the moisture and keep the
exposed tissue from drying out.
5. Provide high-flow oxygen if allowed by
local protocols.
6. Care for shock and initiate transport as
soon as possible.
SHOCK
 Shock is a very complex
process affecting many body
systems.
 Shock is known as
hypoperfusion, results when
there is a failure of one or more
of these processes (adequate
delivery of well-oxygenated
blood and nutrients to the cells
of the body, and the proper
elimination of waste products).
The common types of SHOCK seen after
trauma in the prehospital setting include:
 Hypovolemic shock (vascular volume smaller than
normal vascular size, result of blood and fluid loss)
- Hemorrhagic shock
 Distributive shock (vascular space larger than normal)
- Neurogenic "shock" (hypotension)
 Cardiogenic shock (heart not pumping adequately,
result of cardiac injury)
 Obstructive shock (obstruction of a major vessel causes
less blood to be pumped by the heart)
Types of Shock in Trauma
 Hemorrhagic
Assume hemorrhagic shock in all trauma
patients until proven otherwise
Results from Internal or External Bleeding

A-Hemorrhagic A
hypovolemia:
loss of blood.
B-Nonhemorrhagic
hypovolemia:
loss of plasma
and other fluids.

B
Types of Shock in Trauma
 Obstructive
Cardiac Tamponade
Tension Pneumothorax

Pulmonary Tension Pericardial

embolism pneumothorax tamponade
Types of Shock in Trauma
 Neurogenic
Spinal Cord injury
Neurogenic shock. A form of distributive shock, neurogenic shock is
caused when the spinal cord is damaged and is unable to control the
tone of the blood vessels by way of the sympathetic nervous system.
The vessels are then allowed to dilate uncontrollably. The dilation of
the blood vessels causes an increase in the space within the
circulatory system, which in turn causes a drop in blood pressure,
resulting in inadequate perfusion and shock.
b Distributive shock can be caused
a
by an uncontrolled dilation of
the blood vessels.
A-Normal vessel
B-Dilated vessel with reduced
blood volume
HEMORRHAGIC SHOCK
 Hemorrhagic shock (resulting from blood loss) is categorized
into four classes, depending on the severity and amount of
hemorrhage.
 Hemorrhage is most likely to occur with blunt or penetrating
injuries to vessels or organs, long bone or pelvic fractures,
major vascular injuries (as in traumatic amputation), and
multisystem injury.
Shock occurs in three phases:
 compensated shock,
 decompensated shock,
 irreversible shock.

Your goal is to recognize the

clinical signs and symptoms of
shock in its earliest phase and
begin immediate treatment before
permanent damage occurs
Signs and
symptoms

THE EARLY SIGNS OF THE LATE SIGNS OF

SHOCK are restlessness;
anxiety; altered mental
S SHOCK, appear as the
patient enters
status; increased heart
rate; normal to slightly
H decompensated shock,
are unresponsiveness;
low blood pressure;
mildly increased
O decreasing heart rate;
very low blood pressure;
breathing rate; skin that
is pale, cool, and moist;
C slow, shallow
respirations; skin that is
sluggish pupils; and
nausea and vomiting.
K pale, cool, and moist; and
dilated, sluggish pupils.
ATLS classification of
hemorrhagic shock
CLASS I CLASS II CLASS III CLASS IV

BloodLoss (ml) <750 750-1500 1500-2000 >2000

% 15% 15%-30% 30-40% >40%
HR <100 >100 >120 >140
BP normal normal decrease decrease
PP normal decrease decrease decrease
RR 14-20 20-30 30-40 >35
UOP >30 20-30 5-15 negligible
CNS slightly mildly anxious confused
anxious anxious confused lethargic
Rough BP Estimation from Pulse

• If you can
palpate this 60
pulse, you know
the SBP is
roughly this 80
number 70

80
Shock Index (SI)
 Shock index (SI) is the ratio of heart rate
to systolic blood pressure in mm Hg.
 SI = HR / SBP
 Normal 0.5 - 0.7
 It is commonly used to assess the amount of blood loss and degree
of hypovolemic shock.
 Elevated early in shock
 SI > 0.9 predicts:
– Acute hypovolemia in presence of normal HR & BP
– Marker of injury severity & mortality
 Uses
– The shock index is useful for raising early suspicion of
hypovolemia even when the heart rate and blood pressure
remain normal.
– Prehospital use → triage
– Predict risk for mass transfusion?
Hemorrhagic shock management
Hemorrhagic shock
management
 1. Perform a primary assessment.
 2. Hemorrhage control with mechanical hemostatic adjuncts:

 Tourniquet/junctional tourniquet
 Pressure dressings/thrombin and fibrin impregnated gauze
 3. Keep the patient in a supine position.
 4. Calm and reassure the patient, and maintain a normal body
temperature.
 5. Administer oxygen.
 6. Continue to monitor (Cardiac Monitor, Blood Pressure Monitoring,
Pulseoximetry).
This must be done at least every five minutes!
External bleeding may be
classified as:
 Arterial bleeding. Arterial bleeding occurs when the arteries carrying blood
away from the heart are damaged. The bleeding is often characterized by a
spurting action with each beat of the heart. The color of arterial blood is
bright red because it contains oxygen. Depending on the size of the artery that
has been damaged, a great deal of blood can be lost in a short amount of time.
 • Venous bleeding. Venous bleeding occurs when vessels that return blood to
the heart have been damaged. Veins often lie close to the surface of the skin.
Venous bleeding is characterized by a steady flow of dark red blood.
Depending on the size of the vein affected, venous bleeding can also be
serious.
 • Capillary bleeding. Capillaries are tiny blood vessels that are contained
within the skin. Capillary bleeding is characterized by a slow oozing of bright
red blood from tissues. Capillary bleeding is common with minor scrapes and
abrasions to the skin.
Bleeding management
Combat application
tourniquet (CAT)

A) Pass the tip of the tourniquet into the slit of the

buckle (it already comes like this in the package) and
pull it tightly. Do it like you are buckling a belt around
your waist.
B) Twist the windlass in either direction until the
bleeding stops. You should not need to twist the
windlass on a CAT more than 3 rounds (otherwise it
risks breaking). If the bleeding still has not stopped
when tightened like this, then apply a second one a bit
closer to the centre of the body.
C) Place the windlass inside the clip of the tourniquet
to secure it.
D) Write the time of application on the tourniquet
and on the forehead of the patient where it is visible.
Bleeding management
Emergency bandage
• Multi-functional bandage
for various wounds
• Compact, lightweight,
waterproof, and vacuum
sealed packaging
• Integrated pressure bar
exerts immediate and direct
pressure to the wound and
stop venous bleeding
• Built-in closure bar: no pins,
no clips, no tape, no hook-
and-loop, no knots
• Non-adherent 10,15, 25 cm
pad eliminates pain during
removal and prevents wound
re-opening
Bleeding management
Hemostatic Dressings are key to avoiding
coagulopathy and controlling bleeding early.
– Made of volcanic rock, clay, shells, caoline.
cytozyne
– Actions:
» Direct compression
» Activation of clotting
» Adhesion
– Utility
» Speed of application (under fire)
» Pliable, Z Fold conformation
̶ Primarily used for nonextremity hemorrhage,
but also useful in severely mangled limbs.
IV Access Principles in Shock
• Fastest, simplest route best (antecubital)
• Large bore, short length (14-16 gauge)
Fluid resuscitation typically begins with isotonic
crystalloid solutions, such as lactated Ringer’s lactate.
These solutions have the advantage of being
inexpensive, plentiful, and easy to administer.

◦ Reassess the casualty after each 500 ml IV bolus.

◦ Continue resuscitation until a palpable radial pulse,
improved mental status, or systolic BP of 80-90
mmHg is present.
◦ Discontinue fluid administration when one or more of
the above end points has been achieved.
Hemostatic Resuscitation
For treatment of hemorrhagic shock
the fluid selection priorities are:
- Cold-stored low-titer O whole blood
- Pre-screened low-titer O fresh whole
blood
- Plasma, red blood cells (RBCs) and
platelets in a [Link] ratio
- Plasma and RBCs in a 1:1 ratio
- Plasma or RBCs alone
Small Volume Resuscitation

 Using hypertonic/hyperosmotic fluid

 Remains in vascular space longer
 Restores vascular volume
 Without flooding patient
 Started by military → civilian trauma

Examples:
– Hetastarch (Hespan/Hextend)
– Hypertonic Saline (3% to 7.5%)
Small Volume Resuscitation
Hypertonic Saline
Type:
3.0% and 7.5% Sodium Chloride

Action:
Rapidly pulls fluid from tissues into bloodstream, and
thereby rapidly increasing circulating volume.

Stabilizes BP & CO and controls ICP

1 Liter
250 ml ~ NS or LR
Tranexamic acid
Tranexamic acid (TXA) is a synthetic
derivative of the amino acid lysine that
exerts its antifibrinolytic effect through the
reversible blockade of lysine binding sites
on plasminogen molecules.

 Sig reduction in bleeding without thrombotic

complications
 Reduced bleeding by 30% IF given within 1 hour
 Marked improvement in survival in most
severely injured compared to those who did not
receive it
 Soldiers to carry autoinjectors on battlefield
Tranexamic acid (TXA)

● If a casualty is anticipated to need significant blood

transfusion (for example: presents with hemorrhagic
shock, one or more major amputations, penetrating torso
trauma, or evidence of severe bleeding):
⁃ Administer 1 gm of tranexamic acid in
100 ml Normal Saline or Lactated Ringer’s
as soon as possible but NOT later than 3
hours after injury. When given, TXA
should be administered over 10 minutes by
IV infusion.
⁃ Begin the second infusion of 1 gm TXA
after initial fluid resuscitation has been
completed.
There is a recognition that the onset of hypothermia, acidosis and
coagulopathy in trauma place the patient at high risk for death.

Hypothermia

Trauma
Triad
Death
Coagulopathy Acidosis
Pelvic fracture
 Pelvic injuries are serious because they can damage
major blood vessels and internal organs. Injuries to
these soft tissues can cause profuse internal bleeding
and sterility, and the force that caused the pelvic
injury may also have caused spinal injuries.
The patient may have injuries to the pelvic girdle
(pelvis and hip joints) if:
 The patient complains of pain in the pelvis, hips, or groin.
 The patient complains of pain when gentle pressure is applied
to the sides of the hips or to the hip bones.
 The patient cannot lift the legs while lying face up (supine).
The patient will usually tell you that “It hurts” or “I can’t move
my legs.”
 The foot on the injured side turns
outward (laterally) or inward
(medially) more than the uninjured
side.
 The injured extremity appears
shorter than the uninjured side.
 The pelvis or the hip joint has
noticeable deformity.
Pelvic binder/bed sheet
Pelvic girdle injuries may be
best managed using a
specialized commercial splint.
SAM sling

Or improvised
such as bed sheet
1A Pelvic Binder®
1B SAM-Sling®
1C Trauma Pelvic Orthodic Device®

Before fixation

After fixation
Placement of a Pelvic
Binding Device
 At the level of greater trochanters, NOT the iliac
wings (top of the hip bone.)
Iliac wing – WRONG!

Greater * Note that this

Trochanters is also the level of
the pubic symphysis.

 In one study 40% of the pelvic binders were placed

too high, resulting in inadequate reduction of the
pelvic fracture and possibly increased bleeding.
Don’t Forget!
 External rotation of the lower extremities is commonly seen
in persons with displaced pelvic fractures.
– This may increase the dislocation of pelvic fragments.
– External rotation can be prevented or reduced by
securing the knees or feet together, improving the effect
achieved by the pelvic binder.
 Don’t logroll casualties with
suspected pelvic fractures –
this may increase internal bleeding.
Types of musculoskeletal injuries
 Fracture. A fracture is when bone is broken, chipped, cracked, or splintered. Fractures are
classified as either closed or open. In a closed fracture, the skin is not punctured by the bone
ends, whereas in an open fracture, the skin has been penetrated.
 Dislocation. This occurs when one end of a bone that is part of a joint is pulled or pushed out
of place. Dislocations often result in serious damage to tendons, ligaments, nerves, and blood
vessels because of the way they hold a joint together or weave in and around a joint.
 Sprain. The tough, fibrous tissues called ligaments hold together the bones that make up a
joint. Tendons attach muscle to bones. Excessive twisting forces can cause ligaments and
tendons to stretch or tear, resulting in a sprain injury.
 Strain. A strain is caused by overexerting, overworking, overstretching, or tearing of a
muscle.
Fractures:
Open or Closed
 Open Fracture – associated with an overlying
skin wound
 Closed Fracture – no overlying skin wound

Open fracture Closed fracture

Clues to a
Closed Fracture
• Trauma with significant pain AND
• Marked swelling
• Audible or perceived “snap”
• Different length or shape of limb
• Loss of pulse or sensation distally
• Crepitus (“crunchy” sound)
Field-Expedient
Splint Materials
 Shirt sleeves/safety pins
 Boards
 Boxes
 Tree limbs
 ThermaRest pad
Immobilize fractures/Splinting
Splinting:
- Prevent motion in broken bone ends
- Eliminate further damage
- Distal PMS before and after splinting
- Cover open wounds with sterile dressing
- Immobilize one joint above and below (Apply on side away from
open wound, pad splint well, don’t attempt to push bone ends under
skin)

 Anatomic splints. The person’s body is the splint.

For example, you can splint an arm to the chest or
an injured leg to the uninjured leg.
 Soft splints. Soft materials, such as a folded
blanket, towel, pillow or folded triangular bandage,
can be used for the splint. A sling is a specific kind
of soft splint that uses a triangular bandage tied to
support an injured arm, wrist or hand.
 The ground. An injured leg stretched out on the
ground is supported by the ground.
Immobilize fractures
 Rigid splints. Padded boards, folded
magazines or newspapers, or padded metal
strips that do not have any sharp edges can
serve as splints.
 Formable splints can be molded into various
shapes and combinations to accommodate
the shape of the injured extremity. Examples
of formable splints include vacuum splints,
pillows, blankets, cardboard splints, wire-
ladder splints, and foam-covered moldable
metal splints. Formable splints are best used
for ankle, wrist, and long-bone injuries.
 Traction splints are designed to maintain
mechanical in-line traction to help realign
fractures. Traction splints are most often used
to stabilize femur fractures.
Commercial
Splints
SAM Splint
Painkillers
Pain cannot always be completely relieved. Treatment depends on
the type of pain and its cause.

NSAIDs
Avoid with acute haemorrhage /coagulopathy or critical
illness.
Ibuprofen (200 –400 mgs) iv/po/pr or
Diclofenac (50 mgs) iv/po/pr/im.
Paracetamol 1g iv/po/pr (500 mgs if body weight less
than 50 kgs)
Painkillers
Ketamine 50 mg/ml
The initial dose is 15 to 30 mg IV, 50 mg intranasally, or 50
to 75 mg IM for pain control. Routes: IV,
It does not cause hypotension and, increases heart rate IM, IOS,
and blood pressure, can be used to provide analgesia in intranasal,
patients with decreased BP when narcotic analgesics would oral, and
be inappropriate.
rectal.
- At lower doses, potent analgesia and mild sedation
- At higher doses, dissociative anesthesia and moderate
to deep sedation
- Unique among anesthetics because pharyngeal-
laryngeal
reflexes are maintained
- Cardiac function is stimulated rather than depressed
- Less risk of respiratory depression than morphine
and fentanyl works reliably by multiple routes
- Ketamine has a very favorable safety profile.
Painkillers Fentanyl is a synthetic
opioid.
Morphine/1% 1ml
Morphine is for use in patients with
moderate to severe pain.
Dosage should be titrated to the
patient's response to the pain and
physiologic status.
Adult IV dosage is typically 2.5 to 15
mg (or 0.05 to 0.1 mg/kg), administered
slowly over several minutes while
monitoring the patient for relief and
complications.
Warning: Morphine and Fentanyl
For intramuscular or subcutaneous
Contraindications
administration, the adult dose is 10 mg
- Hypovolemic shock
per 70 kg body weight.
- Respiratory distress
- Unconsciousness
Routes: IV, IM, - Severe head injury
IN or
subcutaneously.
Burns. Classification of Burns
Categories of burns based on source include:
 Heat (thermal) burns, which may be caused by fire, steam, or hot objects.
Chemical burns, which may be caused by caustics, such as acids and alkalis.
Electrical burns, which originate from outlets, frayed wires, and faulty circuits.
Lightning burns, which occur during electrical storms.
Light burns, which occur with intense light. Light from the arc welder or industrial
laser will damage unprotected eyes. Also, ultraviolet light (including sunlight) can burn the
eyes and skin.
Radiation burns, which usually result from nuclear sources.
Most often burns are categorized according to the
depth of the burn

I-degree II-degree III-degree

Burn Depth Characteristics
Total burns surface area
Total burns surface area
Palm method
Palm = 1% Body/Burn Surface Area
 The palm method is easy to use and is
accurate when dealing with smaller
size burn areas
 To estimate the burn area use the
patient's hand, the palm (including
the fingers) equals 1% of the patient’s
burns
 This is not your palm but the patient’s
palm
Burns management
1. Stop the burning process immediately.
2. Flush superficial burns with water (or saline) for several min.
3. Remove smoldering clothing and jewelry. Do not remove
any clothing that is melted onto the skin.
4. Continually monitor the airway. Any burns to the face or exposure to smoke may
cause airway problems.
5. Cover partial- and full-thickness burns with dry, clean dressings.
6. If the eyes or eyelids have been burned, place clean dressings or pads over them.
Moisten these pads with sterile water if possible.
7. If a serious burn involves the hands or feet, always place a clean pad between toes or
fingers before completing the dressing.
8. Provide oxygen and care for shock.
Burns management
9. Fluids should be given to all patients over one
year with burns covering 15% or more of TBSA and
to all infants under one year with burns covering
10% or more of TBSA.
Parkland formula to calculate the patient’s fluid
requirement over the first 24 hours. The formula
tells what volume of Ringer’s lactate to give, in
millilitres.

Parkland formula
Volume (ml) = 4 x body weight (kg) x % TBSA burned
Frostbite
(Local Cold Injury)
 Most injuries from the cold are localized to the
extremities or exposed parts of the body, such as
the tips of the ears, nose, upper cheek, and tips of
the fingers or toes. Frostbite is an ischemic injury
that is classified as superficial, partial thickness, or
full thickness.
Risk Factors for Frostbite.
 Cold exposure without adequate clothing
 Impeding the circulation to the extremities:
•Wearing restrictive or tight clothing
•Smoking, which constricts arteries
•Drinking alcohol, which helps peripherally dilate blood vessels
and causes diuresis
 Fatigue, dehydration, or hunger
 Coming in direct contact with cold objects (conduction)
 Hypothermia (experiencing generalized hypothermia is the most
likely way to sustain a local cold injury)
Frostbite classification
 I - degree. This epidermal injury is limited to skin. The skin appears white or as
yellowish plaque at the site of injury. Skin thaws quickly, feels numb, and appears red
with surrounding edema; healing in 7 to 10 days.
 II-degree. This degree involves all the epidermis and superficial dermis. Tissue feels
stiff to the touch, but tissue beneath gives way to pressure. Superficial skin blister or
vesiculation occurs, with clear or milky fluid after several hours, surrounded by
ecythema and edema. There is no permanent loss of tissue. Healing in 3 to 4 weeks.
 III-degree. This degree involves the epidermis and dermis layers. Frozen skin is stiff,
with restricted mobility. After tissue thaws, skin swells along with a blood-filled blister
(hemorrhagic bulla), indicating vascular trauma to deep tissues; swelling restricts
mobility. Skin loss occurs slowly, leading to mummification and sloughing. Healing is
slow.
 IV-degree. At this level, frozen tissue involves full thickness completely through the
dermis, with muscle and bone involvement. There is no mobility when frozen and
passive movement when thawed. Skin perfusion is poor, and blisters and edema do not
develop. Early signs of necrotic tissue are evident. A slow mummification process will
occur along with sloughing of tissue and autoamputation of nonviable tissue.
Frostbites management:
 Get the patient out of the cold. Take the
patient indoors (depending on
circumstances). Remove wet clothing.
 Do not rub or massage the frostbitten
area (massage will cause further damage
to injured tissues).
 Transport the patient to the hospital with
the injured area elevated.
 Administer analgesia as needed.
 Cover blisters with a dry, sterile dressing.
 Consider rewarming only if the potential
to refreeze does not exist.
IV opiate analgesics are usually required for pain relief and should be initiated before the tissues have
thawed. Initiate IV NaCl with a 250-ml bolus to treat dehydration and reduce blood viscosity and capillary
sludging.
Attempts to begin rewarming of deep frostbite patients in the field can be hazardous to the patient's
eventual recovery and are not recommended unless prolonged transport times (over 2 hours) are involved. If
prolonged transport is involved, thaw the affected part in a warm water bath at a temperature no greater than
37°C to 38.9°C on the affected area until the area becomes soft and pliable to the touch (-30 min).
Administer ibuprofen (12 mg/kg up to 800 mg) if available. NSAIDs such as ibuprofen help decrease
inflammation, pain and inhibit the production of substances that cause vasoconstriction.
Hypothermia

 Hypothermia is defined as a decrease in BT generally

35°C, owing to inadequate thermogenesis and/or
excess environmental cold stress. Extreme cold
weather does not need to be present for a person to
become hypothermic.
 Hypothermia is sometimes also called accidental
hypothermia to distinguish it from therapeutic or
induced hypothermia, which is a key step in the last
link in the chain of survival for comatose patients
with return of spontaneous circulation.
Mechanism of heat loss of the body
Signs and symptoms of hypothermia
Decreasing mental status: Changing vital signs: Decreasing motor and
Amnesia, memory lapses, and Breathing rapid at first; shallow, sensory function:
incoherence slow later; absent near end Stiffness, rigidity
Mood changes Pulse rapid at first; slow and barely Lack of coordination
Impaired judgment palpable later; irregular or absent Exhaustion
Reduced ability to communicate near end Shivering at first,
Dizziness Skin red in early stages, changing little or no shivering later
Vague, slow, slurred, or thick to pale, to cyanotic, to gray, waxen, Loss of sensation
speech and hard; cold to the touch
Drowsiness progressing even to Slowly responding pupils
unresponsiveness Low to absent blood pressure

Estimated Core
Stage Clinical Findings Classical staging of
Temperature ( °C)
Hypothermia I (mild) Conscious, shivering * 35–32 °C accidental
hypothermia
Impaired consciousness based on clinical
Hypothermia II
*; may or may not be <32–28 °C
(moderate)
shivering
signs Copyright
2021 European
Hypothermia III Unconscious *; vital
<28 °C Resuscitation
(severe) signs present Council.
Hypothermia IV Apparent death; vital
Classically < 24 °C **
(severe) signs absent
Principles of pre-hospital management of hypothermia
Treatment of hypothermia
Mild hypothermia
Passive rewarming:
 removing the
patient from the
cold environment,
 optimising
insulation,
 offering food and
warm drinks,
 and promoting
active movements,
Moderate and Severe Hypothermia
 Patients with moderate or severe hypothermia require active rewarming. The whole
body should be insulated to reduce the risk of further cooling. Protection should be
provided against cold, wind, and moisture. A hypothermic patient should be
packaged with several layers.

Attempts to rewarm should not delay transport. They should receive adequate
oxygenation and be placed on a cardiac monitor. When IV or IO fluids are required,
they should be warmed to 38–42 °C and should be given in boluses guided by vital
signs . Use of heated fluids helps to limit secondary cooling and may protect lines from
freezing but has little direct effect on rewarming.
Blast Injuries
 Explosive devices are the most frequently used weapons in
combat. Explosive devices cause human injury by multiple
mechanisms, some of which are exceedingly complex.
Classifications of blast injury
 Primary – injury resulting in direct tissue
damage from the shock wave hitting the body.
 Secondary – injury from fragments
(‘shrapnel’) from a device or the environment.
 Tertiary – injury from displacement of the
body (thrown against a wall/up in the air).
 Quaternary – other types of injury (for
example: burns, inhalation injuries etc).
 Quinary – late complications, for example
fungal infection if major tissue damage.
Blast injury
Catastrophic haemorrhage
Does patient have a traumatic amputation or is this an
isolated injury? Look for other associated injuries:
Blast Thorax – High risk of catastrophic great
vessel and aortic disruption – seek early
cardiothoracic opinion.
Blast Lung – early intubation, lung protective
ventilation from outset and through to ICU care.
Blast Abdomen – risk of significant intra-
abdominal bleeding and late bowel perforation,
even if abdominal wall is not breached.
Blast Pelvis – High mortality rate from
exsanguinations, especially if SI joints are open (of
relevance for landmines, IEDs and floor-based
devices). Apply pelvic binder, gain proximal
control and resuscitate.
Emergency Management Options
 Follow your hospital’s and regional disaster
system’s plan.
 If structural collapse occurs, expect increased
severity and delayed arrival of casualties.
 Aggressive resuscitation is required in close range
survivors.
 Look for a occult injuries and monitor for
evolving injuries.
Compartment Syndrome
Within a limb, groups of muscles are
surrounded by a fascia. Thus, the muscles are
confined to an enclosed space, or compartment,
that can accommodate only a limited amount of
swelling. When bleeding (hematoma) or swelling
occurs within a compartment for any reason but
typically because of a fracture or severe soft-
tissue injury, the pressure within it rises. Pressure
that is too high may prevent blood flow in vessels
supplying the muscles within the same fascial
compartment. This condition, known as
compartment syndrome.
The 5 (or 6) Ps of Compartment Syndrome are
often used as a diagnosis:
Pain
Pallor
Paresthesia - numbness or tingling
Pulse
Paralysis
(Poikilothermia – inability to regulate
temperature i.e. different temperatures between
the affected limb and non-affected limb)
Management
Management should include
elevating the extremity to heart
level (not above!), placing cold
packs over the extremity, and
opening or loosening
constrictive clothing and splint
material.
Give a bolus of an isotonic
crystalloid solution to help the
kidneys flush out toxins from
resulting rhabdomyolysis.
Crush Syndrome
 Crush syndrome occurs because of a prolonged compressive force that
impairs muscle metabolism and circulation and presents following the
extrication or release of an entrapped limb. When limbs are crushed, muscle
tissue becomes ischemic and dies and necrosis develops resulting in release of
harmful products, a process known as rhabdomyolysis.
 After a muscle is compressed for 4 to 6 hours, the muscle cells begin to die and
release their contents into the localized vasculature. When the force compressing
the region is released, blood flow is reestablished and the necrotic tissue is
released into the systemic vasculature.
 The primary substances that are of concern are lactate, potassium and
myoglobin.
 The release of these substances into the circulation can result in decreased blood
pH (a condition known as acidosis).
 Renal failure is another serious complication that may develop after release of
the crushing force.
 Renal dysfunction that results from rhabdomyolysis can lead to significant
electrolyte abnormalities that can cause significant problems: Hyperkalemia
and Hyperphosphatemia
Management
 Assessment of <C>ABCDE
 Administration of High Flow Oxygen
 Assessment and of other bleeding wounds
 Exposure should be as limited as possible especially in hostile or
cold weather conditions.
 Assessment of distal neurovascular status is essential if exposure
is to be kept to a minimum.
 The patient should be released as quickly as possible,
irrespective of the length of time trapped.
 Tourniquets: The use of tourniquets has a important role in the
management of these patients.
Questions?