Detailed Lesson Plan

Chapter 36

Multisystem Trauma and Trauma

in Special Patient Populations

120–140minutes

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
5 / I.Introduction
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 Dispatchand Upon Arrival information from the chapter.
2.Discuss with students how they would proceed. / Case Study Discussion
  • Once you recognize that the patientis pregnant, what specialconsiderations come to mind?
  • What are some common mechanismsof injury in pregnant patients?

30 / II.Multisystem Trauma—Golden Principles of Out-of-Hospital 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. / Animation
Go to click on the mykit link for Prehospital EmergencyCare, 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
Students should be able to apply
the principles of managing multisystemtrauma patients to a varietyof lab scenarios.
Class Activity
Have groups of students prepare multisystem trauma scenarios to demonstrate their understanding of the effects of multisystem trauma. Review thescenarios 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 levelof skill and efficiency needed to care for critically injured multisystemtrauma patients?
15 / III.Trauma in Special Patient Populations—Trauma in Pregnant 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).
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
  1. Abruptio placentae—Separation of the placenta from the uterine wall
  2. Penetrating trauma—Stab wounds to the uterus provide 93 percent morbidity to the fetus.
  3. Motor vehicle crashes—Large percentage of maternal and traumatic injuries
  4. 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. / Discussion Questions
  • What are common causes of injury in pregnant patients?
  • How does the anatomy and physiology of pregnancy affect the response to injuries?

15 / IV.Trauma in Special Patient Populations—Trauma in Pediatric 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.
  1. Assess brachial pulse in an infant.
  2. Blood pressure readings are unreliable in children three years of age or less.
  3. Rely on other signs and symptoms such as skin color, temperature, 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. / Discussion Question
What are the differences in pediatricpatients that account fortheir greater severity of injuriesas compared to adults exposed tosimilar forces?
Weblink
Go to click on the mykit link for Prehospital EmergencyCare, 9th edition to access a web resource on pediatric trauma considerations.
Teaching Tip
Arrange a tour of a pediatricemergency department or, if thisis not possible, consider a tour of the area of the ED in which pediatricpatients are treated.
15 / V.Trauma in Special Patient Populations—Trauma in Geriatric 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.
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. / Weblinks
Go to click on the mykit link for Prehospital EmergencyCare, 9th edition to access web resources on falls in nursing homes and geriatric traumas.
Discussion Question
What are some things that affectthe 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.
15 / VI.Trauma in Special Patient Populations—Trauma in Cognitively 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 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. / Discussion Question
What are some guidelines to followwhen dealing with the cognitivelyimpaired trauma patient?
Knowledge Application
Students should be able to applythe information in this section to scenarios involving assessment and management of pregnant,pediatric, geriatric, and cognitively impaired patients.
5 / VII.Assessment-Based Approach: Multisystem Trauma and Trauma in 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.
5 / VIII. Assessment-Based Approach: Multisystem Trauma and Trauma in 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 click on the mykit link for Prehospital EmergencyCare, 9th edition to access a video on immobilization considerations for pediatric patients.
Animation
Go to click on the mykit link for Prehospital EmergencyCare, 9th edition to access an animation on differences between pediatric and adult trauma patients.
10 / IX.Assessment-Based Approach: Multisystem Trauma and Trauma in Special Patient Populations—Secondary Assessment
A.Physical exam
1.Perform a rapid physical exam, and keep in mind that multiple systems may be affected.
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
  1. When and how did the incident occur?
  2. What is the patient’s chief complaint?
  3. Does the patient have any signs or symptoms associated with the trauma?
  4. Is the patient pregnant? How far along is she? Is there any vaginal bleeding or crowning?
  5. How old is the patient?
  6. Does the patient take any medications? Is the patient allergic to anything?
  7. 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 / Critical Thinking Discussion
How do the psychosocial developmental stages of children of various ages affect their responses to trauma and to treatment byhealth care providers?
5 / X.Assessment-Based Approach: Multisystem Trauma and Trauma in 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.
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. / Discussion Questions
  • What are the priorities of carefor 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?

5 / XI.Assessment-Based Approach: Multisystem Trauma and Trauma in 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. / Knowledge Application
Given a series of scenarios, students should be able to assess and manage a variety of patientsfrom special populations.
10 / XII.Follow-Up
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
/ Case Study Follow-Up Discussion
  • What are some possible injuries causing Mrs. Miller’s signs of shock?
  • What are your concerns for thefetus?
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

PREHOSPITAL EMERGENCY CARE, 9TH EDITION DETAILED LESSON PLAN 36 PAGE1