sanders: mosby's paramedic textbook, revised 3...
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Chapter 20Chapter 20Trauma Systems/Mechanism of InjuryTrauma Systems/Mechanism of Injury
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ObjectivesObjectivesDescribe incidence and scope of traumatic injuries and Describe incidence and scope of traumatic injuries and deathdeath
Identify roles of the trauma systemIdentify roles of the trauma system
Predict injury patterns Predict injury patterns
Describe injury patterns in specific blunt traumaDescribe injury patterns in specific blunt trauma
Describe the role of restraints in injury prevention and Describe the role of restraints in injury prevention and injury patternsinjury patterns
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ObjectivesObjectivesDiscuss how organ motion contributes to injury in each Discuss how organ motion contributes to injury in each body regionbody region
Identify injury patterns associated with motorcycle and Identify injury patterns associated with motorcycle and allall--terrain vehicle collisionsterrain vehicle collisions
Describe pedestrian injury patternsDescribe pedestrian injury patterns
Identify sportsIdentify sports--, blast, blast--, fall, fall--related injuriesrelated injuries
Describe factors influencing tissue damage from Describe factors influencing tissue damage from penetrating traumapenetrating trauma
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Sanders: Mosby's Paramedic Textbook, Revised 3rd Edition PowerPoint Lecture Notes
Chapter 20: Trauma Systems and Mechanism of Injurys
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ScenarioScenarioIt takes a while to find the patient in the It takes a while to find the patient in the woody location. He is a 40woody location. He is a 40--yearyear--old who was old who was shot in the abdomen. His skin is pale and wet, shot in the abdomen. His skin is pale and wet, and his clothes are saturated with blood. You and his clothes are saturated with blood. You administer oxygen, remove his clothing, and administer oxygen, remove his clothing, and load and go, starting two large bore IV lines load and go, starting two large bore IV lines en route. His vital signs are: BPen route. His vital signs are: BP--70 by 70 by palpation, Ppalpation, P--136/min, R136/min, R--28/min.28/min.
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DiscussionDiscussionWhat is your first concern when responding to a What is your first concern when responding to a shooting?shooting?
Why should you try to find out what type of gun and Why should you try to find out what type of gun and ammunition were used?ammunition were used?
What clues can you look for to determine what distance What clues can you look for to determine what distance he was from the shooter?he was from the shooter?
How will you distinguish entrance from exit wounds?How will you distinguish entrance from exit wounds?
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TraumaTraumaEpidemiologyEpidemiologyTrends in trauma deathsTrends in trauma deaths
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Phases of Trauma CarePhases of Trauma Care
Three phasesThree phasesPreincidentPreincidentIncidentIncidentPostincident Postincident
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Prevention of Trauma DeathsPrevention of Trauma Deaths
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Trauma System ComponentsTrauma System ComponentsInjury preventionInjury prevention
Prehospital care Prehospital care
Emergency department careEmergency department care
Interfacility transportation (if needed)Interfacility transportation (if needed)
Definitive careDefinitive care
Trauma critical careTrauma critical care
RehabilitationRehabilitation
Data collection/trauma registryData collection/trauma registry
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Trauma SystemTrauma System
Role of the paramedicRole of the paramedic
Trauma centersTrauma centers
Hospital categorizationHospital categorization
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Transport ConsiderationsTransport Considerations
Level of care and hospital choice is based on:Level of care and hospital choice is based on:Patient needs and conditionPatient needs and conditionAdvice of medical directionAdvice of medical direction
Ground transportGround transport
Aeromedical transportAeromedical transport
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EnergyEnergyTrauma injuriesTrauma injuries
Energy transfer from external source to human bodyEnergy transfer from external source to human body
Extent of injury determined by:Extent of injury determined by:Type of energy appliedType of energy appliedHow quickly it is appliedHow quickly it is appliedTo what part of the body it is appliedTo what part of the body it is applied
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Physics LawsPhysics Laws
Newton's first law of motionNewton's first law of motion
Conservation of energy law Conservation of energy law
Newton's second law of motionNewton's second law of motion
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KinematicsKinematicsPredicting injury patternsPredicting injury patterns
Consider:Consider:PatientPatient’’s ages ageProtective factorsProtective factorsMechanism of injuryMechanism of injuryForce of energy appliedForce of energy appliedAnatomyAnatomyEnergy Energy
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Blunt TraumaBlunt TraumaInjury produced by compression and change of speedInjury produced by compression and change of speed
May disrupt tissueMay disrupt tissue
Direct compression or pressure on a structureDirect compression or pressure on a structureMost common type of force in blunt traumaMost common type of force in blunt trauma
Injury depends on:Injury depends on:Time of compressionTime of compressionForce of compressionForce of compressionArea compressedArea compressed
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Motor Vehicle CollisionMotor Vehicle Collision
Three impacts as energy is transferredThree impacts as energy is transferredVehicle strikes objectVehicle strikes objectOccupant collides with inside of carOccupant collides with inside of carInternal organs collide inside bodyInternal organs collide inside body
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Motor Vehicle CollisionMotor Vehicle Collision
Vehicle crash injuries depend on:Vehicle crash injuries depend on:Type of collisionType of collisionPosition of occupant Position of occupant Use or nonuse of restraint systemsUse or nonuse of restraint systems
•• Active or passiveActive or passive
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Motor Vehicle CollisionMotor Vehicle Collision
Type of impactType of impactHead onHead onLateralLateralRear endRear endRotationalRotationalRolloverRollover
Predictable injury patterns in each type of Predictable injury patterns in each type of collisioncollision
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HeadHead--On (Frontal) ImpactOn (Frontal) Impact
Forward motion stops abruptly: Forward motion stops abruptly: First collisionFirst collisionSecond collisionSecond collisionThird collisionThird collision
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HeadHead--On (Frontal) ImpactOn (Frontal) Impact
Occupant usually travels in pathways relative Occupant usually travels in pathways relative to dashboardto dashboard
Down and underDown and underUp and overUp and over
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DownDown--andand--Under PathwayUnder Pathway
Occupant goes downward Occupant goes downward into vehicle seat and into vehicle seat and forward into dashboard or forward into dashboard or steering columnsteering column
Knees strike dashboardKnees strike dashboardUpper legs absorb impactUpper legs absorb impact
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UpUp--andand--Over PathwayOver Pathway
Body strikes steering Body strikes steering wheelwheel
Momentum of thorax is Momentum of thorax is absorbed by ribs and absorbed by ribs and chest organschest organs
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Lateral ImpactLateral Impact
Vehicle is struck from sideVehicle is struck from side
Injury patterns differ if vehicle:Injury patterns differ if vehicle:Remains in place Remains in place Moves away from point of impactMoves away from point of impact
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RearRear--End ImpactEnd ImpactVehicle struck from behind Vehicle struck from behind
Rapidly acceleratesRapidly acceleratesAuto moves forward under occupantAuto moves forward under occupant
Forward collisionsForward collisionsDamage = Sum of both vehicles' speedsDamage = Sum of both vehicles' speeds
RearRear--end collisionsend collisionsDamage = Difference between two vehiclesDamage = Difference between two vehicles’’ speeds speeds
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Rotational ImpactRotational Impact
OffOff--center portion of vehicle strikes an center portion of vehicle strikes an immovable objectimmovable object
Or one that is moving:Or one that is moving:•• More slowlyMore slowly•• In the opposite directionIn the opposite direction
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Rollover AccidentsRollover AccidentsOccupant tumbles inside autoOccupant tumbles inside auto
Injured wherever body strikes vehicleInjured wherever body strikes vehicleImpacts at many different anglesImpacts at many different anglesMay be multipleMay be multiple--system injuriessystem injuries
Injuries difficult to predictInjuries difficult to predictMay produce any injury pattern seen in other types May produce any injury pattern seen in other types of collisionsof collisions
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RestraintsRestraints
Lap beltsLap belts
Shoulder strapsShoulder straps
AirbagsAirbags
Child safety seatsChild safety seats
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Deceleration InjuriesDeceleration Injuries
After impact organs continue to pull against After impact organs continue to pull against structures that attach them to the bodystructures that attach them to the body
Organs may separate from attachmentsOrgans may separate from attachmentsVascular pedicle or mesenteric attachment injury Vascular pedicle or mesenteric attachment injury may cause hemorrhagemay cause hemorrhage
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Head InjuriesHead InjuriesHead strikes stationary Head strikes stationary objectobject
Cranium stops abruptly Cranium stops abruptly
Brain continues moving Brain continues moving and is compressed and is compressed against skullagainst skull
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Thoracic InjuriesThoracic InjuriesAorta often injured by Aorta often injured by severe deceleration severe deceleration forcesforces
Usually sheared at Usually sheared at ligamentum arteriosum ligamentum arteriosum attachmentattachment
Rupture causes rapid Rupture causes rapid exsanguinationexsanguination
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Abdominal InjuriesAbdominal Injuries
Abdominal organs and Abdominal organs and retroperitoneal retroperitoneal structures (most structures (most commonly the kidneys) commonly the kidneys) may be affected by may be affected by deceleration forcesdeceleration forces
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Head InjuriesHead InjuriesCompression to head may cause:Compression to head may cause:
Open fracturesOpen fracturesClosed fracturesClosed fracturesBone fragment penetration (depressed skull Bone fragment penetration (depressed skull fracture)fracture)
Associated injuriesAssociated injuriesBrain contusionBrain contusionLacerations of brain tissueLacerations of brain tissue
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Head InjuriesHead InjuriesCompression forces to skull can produce Compression forces to skull can produce hemorrhage from:hemorrhage from:
Fractured boneFractured boneMeningeal vesselsMeningeal vesselsBrainBrain
If facial structures are involved, soft tissue If facial structures are involved, soft tissue trauma and facial bone fractures may occurtrauma and facial bone fractures may occur
Consider CNS injury and cervical fractureConsider CNS injury and cervical fracture
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Head InjuriesHead Injuries
Compression injury to vertebral bodiesCompression injury to vertebral bodiesCompression fractureCompression fractureHyperextension injuryHyperextension injuryHyperflexion injuryHyperflexion injury
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Thoracic InjuriesThoracic Injuries
Lungs and heart often Lungs and heart often involved in compression involved in compression injury to thoraxinjury to thorax
““Paper bag effectPaper bag effect”” may may cause serious lung cause serious lung injuryinjury
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Abdominal InjuriesAbdominal InjuriesCompression injuriesCompression injuries
Solid organ ruptureSolid organ ruptureVascular organ hemorrhageVascular organ hemorrhageHollow organ perforation into peritoneal cavityHollow organ perforation into peritoneal cavity
Common injuriesCommon injuriesLacerations to spleen, liver, and kidneyLacerations to spleen, liver, and kidneyRupture of a full bladderRupture of a full bladder
Predictable injuriesPredictable injuries
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Other Motorized Vehicular CollisionsOther Motorized Vehicular CollisionsAllAll--terrain vehicles (ATVs)terrain vehicles (ATVs)
SnowmobilesSnowmobiles
Motor boatsMotor boats
Water bikesWater bikes
Jet skisJet skis
Farm machineryFarm machinery
MotorcyclesMotorcycles
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Motorcycle CollisionsMotorcycle CollisionsHeadHead--on impacton impact
Rider over handlebarsRider over handlebars
Injuries may include:Injuries may include:Head and neckHead and neckChest and abdomenChest and abdomenFemur, lower leg fracturesFemur, lower leg fracturesPerineal injuriesPerineal injuries
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Motorcycle CollisionsMotorcycle Collisions
Angular impactAngular impact
Rider caught between bike and another Rider caught between bike and another objectobject
Crush injuries to affected sideCrush injuries to affected sideOpen fractures of femur, tibia, fibulaOpen fractures of femur, tibia, fibulaFracture dislocation of malleolusFracture dislocation of malleolus
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Motorcycle CollisionsMotorcycle Collisions
Laying the motorcycle Laying the motorcycle downdown
Massive abrasionsMassive abrasions
Fractures of affected sideFractures of affected side
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Personal Protective EquipmentPersonal Protective Equipment
Riders of small motor vehiclesRiders of small motor vehiclesBootsBootsLeather clothingLeather clothingEye protectionEye protectionHelmetsHelmets
•• Absorb energy, reduce head and facial injuriesAbsorb energy, reduce head and facial injuries•• Helmet nonHelmet non--use increases head injuries > 300%use increases head injuries > 300%
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Pedestrian InjuriesPedestrian Injuries
Impacts in autoImpacts in auto--pedestrian collisionspedestrian collisionsBumper of vehicle strikes bodyBumper of vehicle strikes bodyPedestrian strikes vehicle hoodPedestrian strikes vehicle hoodPedestrian strikes ground or another objectPedestrian strikes ground or another object
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Pedestrian InjuriesPedestrian Injuries
Predictable injuries depend on:Predictable injuries depend on:Age of pedestrianAge of pedestrianHeight of pedestrian relative to bumper and hood Height of pedestrian relative to bumper and hood of carof carVelocity of vehicleVelocity of vehicle
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Adult PedestrianAdult PedestrianMost turn away from oncoming autoMost turn away from oncoming auto
Lateral or posterior impactsLateral or posterior impacts
Initial impactInitial impact
Second impactSecond impact
Third impact Third impact
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Child PedestrianChild PedestrianTend to face vehicleTend to face vehicle
Often frontal impactOften frontal impact
Initial impactInitial impact
Second impactSecond impact
Third impactThird impact
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Common Sports InjuriesCommon Sports InjuriesContact sportsContact sports
FootballFootballBasketballBasketballHockeyHockeyWrestlingWrestling
Racquet sportsRacquet sports
Swimming and divingSwimming and diving
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Common Sports InjuriesCommon Sports Injuries
HighHigh--velocity activity sportsvelocity activity sportsDownhill skiingDownhill skiingWater skiingWater skiingBicyclingBicyclingRollerbladingRollerbladingSkateboardingSkateboarding
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Causes of SportsCauses of Sports--Related InjuriesRelated InjuriesForces of acceleration and decelerationForces of acceleration and deceleration
CompressionCompression
TwistingTwisting
HyperextensionHyperextension
HyperflexionHyperflexion
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Blast InjuriesBlast InjuriesExplosion of volatile substancesExplosion of volatile substances
Primary blast injuriesPrimary blast injuriesSecondary blast injuriesSecondary blast injuriesTertiary blast injuriesTertiary blast injuries
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Vertical FallsVertical FallsEvaluate:Evaluate:
Distance fallenDistance fallenBody position on impactBody position on impactType of landing surface Type of landing surface
Vertical fall injuries a result of deceleration Vertical fall injuries a result of deceleration and compressionand compression
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Penetrating TraumaPenetrating Trauma
Cause tissue disruption Cause tissue disruption Despite velocityDespite velocityPenetrating traumaPenetrating trauma
Two forcesTwo forcesCrushingCrushingStretchingStretching
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Penetrating TraumaPenetrating Trauma
Factors that determine which of the two Factors that determine which of the two mechanisms of injury predominates:mechanisms of injury predominates:
Character of penetrating objectCharacter of penetrating objectSpeed of penetrationSpeed of penetrationType of tissue it passes through or intoType of tissue it passes through or into
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CavitationCavitation
Opening produced by a force pushing body Opening produced by a force pushing body tissues laterally away from tract of a projectiletissues laterally away from tract of a projectile
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CavitationCavitation
Cavitation related to:Cavitation related to:Tissue density Tissue density Ability of tissue to return to its original shape and Ability of tissue to return to its original shape and positionposition
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Permanent and Temporary CavitationPermanent and Temporary Cavitation
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BallisticsBallisticsProjectileProjectile’’s effect on body determined by s effect on body determined by energy created and dissipated by object into energy created and dissipated by object into surrounding tissuessurrounding tissues
Damage and energy levels of projectilesDamage and energy levels of projectilesLow, medium, and highLow, medium, and high
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LowLow--Energy ProjectilesEnergy ProjectilesKnives, needles, and ice picksKnives, needles, and ice picks
Sharp cutting edges cause tissue damageSharp cutting edges cause tissue damage
Tissue crushed is usually small because Tissue crushed is usually small because wounding force is smallwounding force is small
Damage usually limited to pathway of Damage usually limited to pathway of projectileprojectile
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Stab WoundStab WoundStab wound in which a knife has pierced the liver and pancreas
and entered the splenic vein
Fig 20-13Fig 20-13
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Stab WoundsStab WoundsAttempt to identify wounding objectAttempt to identify wounding object
Consider:Consider:Multiple woundsMultiple woundsEmbedded penetrating objectsEmbedded penetrating objectsDamage to organs of thorax and abdomenDamage to organs of thorax and abdomenPenetration of multiple body cavitiesPenetration of multiple body cavitiesStab wounds to back and flankStab wounds to back and flank——high riskhigh risk
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MediumMedium--Energy InjuriesEnergy Injuries
Muzzle velocity of <1500 ft per secMuzzle velocity of <1500 ft per sec
Handguns and some rifles Handguns and some rifles
Injury tract usually 2Injury tract usually 2--3 times diameter of 3 times diameter of projectileprojectile
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HighHigh--Energy InjuriesEnergy Injuries
Muzzle velocity of >1500 ft per secMuzzle velocity of >1500 ft per sec
Injury tract usually 2Injury tract usually 2--3 times diameter of 3 times diameter of projectileprojectile
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MediumMedium-- and Highand High--Energy ProjectilesEnergy Projectiles
Localized crushing of tissue in missile's pathLocalized crushing of tissue in missile's path
Momentary stretch of surrounding tissuesMomentary stretch of surrounding tissues
Wounds vary with amount and location of Wounds vary with amount and location of crushed and stretched tissuecrushed and stretched tissue
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Wounding ForcesWounding ForcesWounding forces depend on:Wounding forces depend on:
Projectile massProjectile massDeformationDeformationFragmentationFragmentationType of tissue struckType of tissue struckStriking velocityStriking velocityRangeRange
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Wounding ForcesWounding ForcesBullet passing through tissue
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Shotgun WoundsShotgun Wounds
Short range, low velocity Short range, low velocity
Tissue damage depends on:Tissue damage depends on:Gauge of gunGauge of gunSize of pelletsSize of pelletsPowder chargePowder chargeDistance from victimDistance from victim
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Entrance and Exit WoundsEntrance and Exit Wounds
Appearance of entrance and exit wounds Appearance of entrance and exit wounds affected by:affected by:
RangeRangeBarrel lengthBarrel lengthCaliberCaliberPowderPowderWeaponWeapon
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Entrance WoundEntrance Wound
Round or ovalRound or oval
May be abrasion rim or collarMay be abrasion rim or collar
If discharged at intermediate or close range:If discharged at intermediate or close range:Powder burns (tattooing) may be presentPowder burns (tattooing) may be present
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Bullet Wound Bullet Wound Powder marks show this 0.22-caliber bullet wound was inflicted at close range
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Shotgun WoundShotgun WoundShort-range shotgun wound to forearm
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Exit WoundsExit Wounds
Generally larger than entrance woundsGenerally larger than entrance wounds
Skin may Skin may ““explodeexplode””::Ragged and torn tissueRagged and torn tissueSplitting and tearing often produces a starSplitting and tearing often produces a star--burst or burst or stellate woundstellate wound
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Exit WoundExit WoundExit wound by powerful shotgun at close range
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Head InjuriesHead Injuries
Gunshot wounds to head are typically Gunshot wounds to head are typically devastating devastating
Often severe facial and neck injuriesOften severe facial and neck injuries•• Significant blood lossSignificant blood loss•• Difficulty maintaining airway controlDifficulty maintaining airway control•• Spinal instabilitySpinal instability
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Thoracic Gunshot InjuriesThoracic Gunshot Injuries
Severe injury to pulmonary and vascular Severe injury to pulmonary and vascular systems possiblesystems possible
Pneumothorax and tension pneumothorax Pneumothorax and tension pneumothorax Internal and external hemorrhageInternal and external hemorrhageThoracic trauma possible without visible chest Thoracic trauma possible without visible chest woundswounds
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Abdominal Gunshot InjuriesAbdominal Gunshot Injuries
Surgery often needed to determine extent of Surgery often needed to determine extent of injuryinjury
May affect multiple organ systemsMay affect multiple organ systemsDamage to airDamage to air--filled and solid organsfilled and solid organsVascular injuryVascular injurySpinal column and spinal cord injurySpinal column and spinal cord injury
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Extremity InjuriesExtremity Injuries
Gunshot wounds to extremities:Gunshot wounds to extremities:Occasionally life threateningOccasionally life threateningMay result in lifelong disabilityMay result in lifelong disability
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ConclusionConclusionThe paramedic must understand trauma The paramedic must understand trauma
systems and be able to recognize systems and be able to recognize mechanisms of injury to enhance patient mechanisms of injury to enhance patient
assessment and emergency care.assessment and emergency care.
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Questions?Questions?
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