Crush Injuries and Blunt Trauma on the Fireground: Concepts of Initial Management

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Crush Injuries and Blunt Trauma on the
Fireground Concepts of Initial Management

• Travis R. Welch, EMS Director
• Zionsville Fire Department

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References

• Fire Service Emergency Care, Brady
• Essentials of Emergency Care, Delmar
• ZFD/BCEMS BLS protocols

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Objectives

• At the completion of this block of instruction,
  the participant will be able to competently
• Identify possible mechanisms of injury resulting
  in fireground crush injury.
• Assess a patient with a possible crush injury
• Initiate proper initial BLS care for a patient
  with crush injury
• Demonstrate a basic understanding of the
  pathophysiology of crush injuries, the required
  treatment, and resources available.

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Crush Injury Defined

• Injuries in which damaging forces are passed from
  the exterior of the body to internal structures
  because the body or some part of it has been
  compressed between to or more surfaces.
• May result in open or closed wounds

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Patient Assessment

• Scene Size up
• Primary Survey treat immediate life threats
• Secondary Survey prioritize and treat other
  injuries, reassess all interventions done
  previously

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How can it occur?

• What are some of the mechanisms by which we as
  responders, or the victims on our emergency
  scenes may receive crushing injuries?

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Size-up

• Ensure scene/responder safety
• Determine possible mechanisms of injury
• Immediate life threats?
• Do you need additional resources?

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Primary Survey

• A-airway with C-Spine control
• B-Breathing, rate and quality
• C-Circulation (pulses)
• D-Disability (mental) Is the Pt alert?
• E-Expose You cant treat it if you dont see it
• F-Full set of vitals

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Secondary Survey

• Head to toe, review as you go
• Detailed physical exam from head to toe
• Prioritize injuries
• Reassess aspects of primary survey and any
  treatment started during primary survey
• Continuous process

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What types of injuries might you see? How do you
treat them?

• Musculoskeletal
• Fractures
• Dislocations
• Soft tissue
• Lacerations
• Puncture wounds
• Avulsions/eviscerations
• Multi-system trauma or vascular injury
• And many more
• all for 3 easy payments of 19.95!

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MS Injuries

• Fractures
• Dislocations
• Sprains
• Strains

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Fractures

• Closed
• Open
• Non-displaced
• Displaced

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Signs of Bone Fracture

• Deformity
• Tenderness
• Splinting
• Swelling
• Bruising

• Crepitus
• False motion
• Exposed fragments
• Pain
• Locked joint

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Emergency CareFractures

• Dress open wounds.
• Apply appropriate splint.
• If swelling is present, apply ice packs.
• Prepare patient for transport.

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Amputations

• Apply dressing and immobilize.
• Wrap amputated part in sterile dressing.
• Place in plastic bag.
• Follow local protocol for preserving amputated
  part.
• Transport with patient.

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Soft Tissue Injuries

• Closed
• Open
• Burns

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Closed Injuries

• Contusion
• Ecchymosis
• Hematoma
• Compartment syndrome

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Closed InjuriesEmergency Care

• Use BSI techniques.
• Ice or cold pack
• Compression
• Elevation
• Splinting
• Treat for shock if necessary.

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Open Injuries

• Abrasion
• Laceration
• Avulsion
• Penetrating wound
• Amputation

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Open InjuriesEmergency Care

• Use BSI techniques.
• Ensure airway.
• Assess wound and control bleeding.
• Apply sterile dressing.
• Immobilize impaled objects.

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Splinting (1 of 2)

• Apply unless patients life is in immediate
  danger.
• Prevents further damage to injured area
• Prevents an open fracture from occurring
• Prevents excessive bleeding

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Splinting (2 of 2)

• Maintains circulation in extremity
• Reduces pain
• Prevents neurological damage to injured area

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Principles of Splinting (1 of 3)

• Expose the injury.
• Assess and record neurovascular status.
• Cover all open wounds.
• Avoid moving patient before splinting.

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Principles of Splinting (2 of 3)

• Immobilize joint above and below site.
• Immobilize bones above and below joint.
• Pad all rigid splints.

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Principles of Splinting (3 of 3)

• Align the extremity.
• If you encounter resistance, splint as is.
• Immobilize suspected spinal injuries in a
  neutral in-line position.
• If the patient shows signs of shock, align in
  normal position and transport.
• When in doubt, splint.

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Spinal Injuries

• Motor vehicle crashes
• Pedestrian-motor vehicle collisions
• Falls
• Penetrating trauma to the head, neck, or torso
• Motorcycle crashes
• Hangings
• Diving accidents
• Recreation and sport trauma

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Assessment of Spinal Injuries (1 of 2)

• Evaluate mechanism of injury (MOI).
• Always assume spinal injury when MOI unknown.
• Use manual immobilization and spinal precautions.
• Tell patient to keep head and injured areas still.

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Assessment of Spinal Injuries (2 of 2)

• Gentle palpation of affected area.
• Minimize movement.
• Determine extremity strength by squeezing hands
  test.
• Gently push each foot against hands.

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Assessment QuestionsPossible Spinal Injury

• Neck or back hurt?
• What happened?
• Where does it hurt?
• Able to wiggle fingers and toes?
• Able to sense with fingers and toes?

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Signs and SymptomsSpinal Injury

• Pain, tenderness and/or deformity
• Pain along spinal column
• Paresthesia and/or numbness below site
• Paralysis below injury site
• Trauma to the shoulders, back, or abdomen

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Emergency CareSpinal Injuries (1 of 2)

• Maintain airway.
• Use jaw-thrust maneuver to stabilize spine in a
  neutral, in-line position.
• Perform manual in-line immobilization.
• Apply cervical collar.

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Emergency CareSpinal Injuries (2 of 2)

• Immobilize supine patients on backboard.
• Use short backboard on sitting patients.
• Use standing backboard on standing or walking
  patient.

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Specific Considerations

• Compartment Syndrome
• Traumatic Asphyxia

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Compartment Syndrome

• Characterized by the "five P's"--pain,
  paresthesia, paralysis, pallor, and
  pulselessness--although pulselessness and
  abnormal capillary refill are late signs.
• Requires surgical intervention
• Occurs when trauma produces swelling into
  internal spaces in extremitieswhich puts
  pressure on vital structures such as nerves or
  blood vessels

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Traumatic Asphyxia

• Characterized by cyanosis of upper body
• Requires immediate transport, aggressive
  oxygenation
• Poor prognosis

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Questions?

• Now, break into groups and practice
  immobilization techniques, including a patient in
  PPE and SCBA.