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Appendices
These appendices provide additional information to enhance the
doctors knowledge of trauma-related issues.
TABLE OF CONTENTS1 Triage Scenarios
...........................................................................................................................................293308
2 Injury Prevention
.........................................................................................................................................309314
Table 1, Haddons Factor-phase Matrix for Motor Vehicle Crash
Prevention ............................................310
3 Biomechanics of Injury
...............................................................................................................................315336
Figure 1, Cavitation
..............................................................................................................................................318
Figure 2, Frontal Impact, Unrestrained
Driver.................................................................................................320
Figure 3, Rear Impact, Improper and Proper Headrest
Use...........................................................................321
Figure 4, Braking VehicleRestrained
Occupant............................................................................................323
Figure 5, CollisionUnrestrained
Occupant....................................................................................................324
Figure 6, CollisionRestrained Occupant
........................................................................................................325
Figure 7, Proper Versus Improper Lap Belt Application
................................................................................327
Figure 8, Adult Pedestrian Injury Triad
............................................................................................................328
Figure 9, Cavitation
Results.................................................................................................................................331
Figure 10, Ballistics Tumble and
Yaw................................................................................................................332
Table 1, Missile Kinetic
Energy...........................................................................................................................333
4 Tetanus
Immunization................................................................................................................................337340
Table 1, Wound
Classification.............................................................................................................................338
Table 2, Summary of Tetanus Prophylaxis for the Injured Patient
...............................................................339
5 Trauma Scores: Revised and
Pediatric.....................................................................................................341344
Table 1, Revised Trauma Score
...........................................................................................................................343
Table 2, Pediatric Trauma Score
.........................................................................................................................344
6 Sample Trauma Flow Sheet
.......................................................................................................................345350
7 Ocular Trauma (Optional Lecture)
............................................................................................................351356
8 Injury Care in Austere and Hostile Environments (Optional
Lecture)..............................................357372
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APPENDIX 1
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APPENDIX 1
1Triage ScenariosAPPENDIX INTRODUCTIONThis is a self-assessment
exercise, to be completed before you arrive for the course. Please
read through the introductory information on the following pages
before reading the individual scenarios and answering the related
questions. This skills station is conducted in a group discussion
format in which your participation is expected. Upon completion of
this session, you will receive a booklet of prepared responses for
each sce-nario.
The goal of this station is to apply trauma triage principles in
multiple patient scenarios.
Upon completion of this session, the participant will be able
to:
A. Define triage.
B. Understand and describe the principles involved and the
factors that must be considered in the triage process.
C. Apply the principles of triage with the use of actual
scenarios.
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I. DEFINITION OF TRIAGE
Triage is a process by which management of mul-tiple patient
casualties is prioritized.
II. PRINCIPLES OF TRIAGE
A. Degree of Life Threat Posed by the Injury (ABCDEs of
Care)
The degree of life threat posed by each injury is de-termined by
considering the order of priorities in the primary survey of an
individual patient and apply-ing these same principles to groups of
patients. In this system the patient with an airway or breathing
problem takes priority over a patient with a circula-tory or
neurologic disability.
B. Injury Severity
The overall severity of injury in a particular patient may be
related not only to an individual injury, but also to the effects
of different injuries and how the patient responds to all of these
injuries in a global sense. For instance, an isolated fracture may
be of low priority. However, when it is combined with an-other
source of major hemorrhage, which increases the overall injury
severity, the priority level in the triage process also may
increase.
C. Salvageability
The patient with the most severe injury or the great-est threat
to life is not necessarily the patient that receives top priority
when dealing with multiple pa-tient scenarios. Consideration must
be given to the likelihood of survival of the patient. In this
system the patient who is least likely to survive in spite of
having the most severe injuries is often relegated to a lower
priority and is managed after patients who are considered more
salvageable.
D. Resources Including Capability of Personnel and Equipment
The patient whose needs exceed the resource capa-bilities is
given a lower priority until the necessary resources are
secured.
E. Time, Distance, Environment
An injury that can be managed very quickly, al-though of lower
severity and lower life threat, may be treated as a higher priority
because of the
short length of time taken for correcting the identi-fied
problem. Distance for travel in transporting a patient to
definitive care and other environmental factors also need to be
considered in prioritizing management of multiple patient
scenarios.
III. APPLICATION OF TRIAGE PRINCIPLES
Triage is often based on incomplete information because the
detailed information on the status of a patient may not be
immediately obvious. However, decisions have to be made on the best
information available. Frequently it is not possible to obtain such
parameters as vital signs on the victims in multiple casualties.
Indeed, it is necessary in many instances to make decisions by
surveying an entire situation at a distance and determining on that
basis which of the patients is the most severely injured. Simple
factors (eg, a patient shouting in agony as opposed to one lying
still with noisy breathing that can be detected from a distance)
could be cues that would allow a decision to approach one patient
with a po-tential airway problem before approaching another patient
who may have a fractured extremity causing intense pain but not
necessarily producing a major threat to life.
An important concept is to avoid indecision and proceed quickly
with incomplete information be-cause time is of the essence in the
entire triaging pro-cess. In some situations, it may be possible to
obtain information such as vital signs, etc from prehospital
personnel. Such information should be used in pri-oritizing the
management of multiple victims.
As a general rule, the order of priorities in multiple victim
scenarios is the same as in an individual pa-tient where airway (A)
takes priority over breathing (B) and circulation (C). Therefore,
the patient with an airway problem is managed before a patient with
a circulatory problem. However, in some instances it may be
necessary to prioritize patients based on sal-vageability. For
example, a patient who has the least chance of survival, although
being the most severely injured, may not be managed before a
patient who can be stabilized very quickly and who has a prob-lem
that can be easily and rapidly reversed.
Triage decisions involving salvageability, in most situations,
are dependent on assessment of the need for definitive care and not
emergency care. Available resources and time/distance factors must
be consid-ered when making these decisions. For example, 3
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patients with intraabdominal injuries present with hypotension.
They would be triaged differently if 1 had a fractured limb and the
other 2 had severe head injuries. Additionally, the 2 with severe
head injuries would be triaged differently if 1 also had a
suspected aorta disruption.
The triage process also involves identification of the necessary
resources for stabilizing patients. If these
resources are not available, the patient may not be given the
same priority in the triage process.
Part of the triage process also may involve a deter-mination of
the most appropriate mode of transfer as well as the most
appropriate institution to which the patient should be transferred
based on the na-ture of the injuries and the resources required for
managing the patient definitively.
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Triage Scenario IGas Explosion in the Gymnasium
Scenario: You are summoned to a triage area at a construction
site where 5 workers are injured in a gas explosion during the
renovation of a gymnasium ceiling. After you quickly survey the
situation, the patients conditions are as follows:
Patient AA young man is screaming, Please help me, my leg is
killing me!
Patient BA young woman is cyanotic, tachypneic, and breathing
very noisily
Patient CA 50-year-old man is lying in a pool of blood with his
left trouser leg soaked in blood
Patient DA young man is lying face down on a stretcher and not
moving
Patient EA young man is swearing expletives and shouting that
someone should help him or he will call his lawyer.
Questions for Response:
1. Identify what you perceive to be the primary problem
requiring treatment.
Patient A is a young man screaming Please help me, my leg is
killing me!
Possible
Injury/Problem:________________________________________________________________
Patient B appears cyanotic and tachypneic, and is breathing very
noisily.
Possible
Injury/Problem:________________________________________________________________
Patient C is a 50-year-old man lying in a pool of blood with his
left trouser leg soaked in blood.
Possible
Injury/Problem:________________________________________________________________
Patient D is lying face down on a stretcher and not moving.
Possible
Injury/Problem:________________________________________________________________
Patient E is swearing expletives and shouting that someone
should help him or he will call his lawyer.
Possible
Injury/Problem:________________________________________________________________
(Proceed to next page for continuation of Scenario I.)
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Triage Scenario IGas Explosion in the Gymnasium continued
2. Establish your patient priorities for further evaluation by
placing a number #1 through #5 (with #1 being your highest priority
and #5 being your lowest priority) in the space provided next to
each patient letter.
_____ Patient A
_____ Patient B
_____ Patient C
_____ Patient D
_____ Patient E
3. Briefly outline your rationale for prioritizing these
patients in the manner you did.
Priority 1Patient _____:Rationale:
________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Priority 2Patient _____:Rationale:
________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Priority 3Patient _____:Rationale:
________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Priority 4Patient _____:Rationale:
________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Priority 5Patient _____:Rationale:
________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
(Proceed to next page for continuation of Scenario I.)
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Triage Scenario IGas Explosion in the Gymnasium continued
4. Briefly, describe what basic life support maneuvers or
additional assessment techniques you would employ to further
evaluate the problem(s).
Priority 1Patient _____:Basic life support maneuvers or
additional assessment
techniques:________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Priority 2Patient _____:Basic life support maneuvers or
additional assessment
techniques:________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Priority 3Patient _____:Basic life support maneuvers or
additional assessment
techniques:________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Priority 4Patient _____:Basic life support maneuvers or
additional assessment
techniques:________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Priority 5 Patient _____:Basic life support maneuvers or
additional assessment
techniques:________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
(Proceed to Scenario II, which is a continuation of this
scenario.)
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Triage Scenario IIGas Explosion in the Gymnasium continued
Continuation of Scenario I:
1. Characterize the patients according to who receives basic or
advanced life support care and describe what that care would be.
List the patients in the priority order as you identified them in
Scenario I, starting with your first priority. Insert a mark in the
box under BLS and/or ALS according to your decision of what the
patient needs.
Patient BLS ALS Description of Care
____________
__________________________________________________________
_____________________________
_____________________________
____________
__________________________________________________________
_____________________________
_____________________________
____________
__________________________________________________________
_____________________________
_____________________________
____________
__________________________________________________________
_____________________________
_____________________________
____________
__________________________________________________________
_____________________________
_____________________________
(Proceed to next page for continuation of Scenario II.)
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Triage Scenario IIGas Explosion in the Gymnasium continued
2. Prioritize patient transfers and identify destinations.
Provide a brief rationale for your destination choice.
Priority Patient Destination
1 ____________ Trauma center Nearest
hospital____________________________________________________________________________________________________________________________________________________________________________________
2 ____________ Trauma center Nearest
hospital____________________________________________________________________________________________________________________________________________________________________________________
3 ____________ Trauma center Nearest
hospital____________________________________________________________________________________________________________________________________________________________________________________
4 ____________ Trauma center Nearest
hospital____________________________________________________________________________________________________________________________________________________________________________________
5 ____________ Trauma center Nearest
hospital____________________________________________________________________________________________________________________________________________________________________________________
3. In situations involving multiple patients, what criteria
would you use to identify and prioritize the management of these
patients?
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
4. What cues can you elicit that would be of assistance in
triage?____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
(Proceed to next page for continuation of Scenario II.)
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Triage Scenario IIGas Explosion in the Gymnasium continued
5. Which patient injuries or complaints should receive treatment
at the scene before prehospital per-sonnel arrive?
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
6. After prehospital personnel arrive, what techniques should be
instituted and what principles govern the order of initiation of
such techniques? Attention should be directed at
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
7. In multiple patient situations, who should be transported?
Who should be transported early?
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
8. Who could have treatment delayed and be transported
later?
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
(Proceed to next page for Scenario III.)
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Triage Scenario IIITrailer-home Explosion and Fire
Scenario: An explosion and fire, due to a faulty gas line, has
involved 1 trailer in a nearby trailer park. Because of the close
proximity of the incident to the hospital, the prehospital
personnel transport the pa-tients directly to the hospital without
prior notification. The 5 patients, all members of the same family,
are immobilized on long spine boards when they arrive at your small
hospital emergency department. The injured patients are:
Patient AA 45-year-old man is coughing and expectorating
carbonaceous material. Hairs on his face and head are singed. His
voice is clear and he is complaining about pain in his hands, which
have ery-thema and early blister formation.
VS: BP 120 mm Hg systolic, HR 100, and RR 30
Patient BA 6-year-old girl appears frightened and is crying. She
complains of pain from burns (erythema/blisters) over her back,
buttocks, and both legs posteriorly.
VS: BP 110/70 mm Hg, HR 100, and RR 25
Patient CA 70-year-old man is coughing, wheezing, and
expectorating carbonaceous material. His voice is hoarse and he
responds only to painful stimuli. There are erythema, blisters, and
charred skin to the anterior chest and abdominal walls and
circumferential burns of both thighs.
VS: BP 80/40 mm Hg, HR 140, and RR 35
Patient DA 19-year-old woman is obtunded but responds to pain
when her right humerus and leg are moved. There is no obvious
deformity of the arm, and the thigh is swollen while in a traction
splint.
VS: BP 140/90 mm Hg, HR 110, and RR 32
Patient EA 45-year-old man is pale and spontaneously complaining
of pain in his pelvis. There is clini-cal evidence of fracture with
abdominal distention and tenderness to palpation. There is erythema
and blister of the anterior chest and abdominal walls and thighs.
He also has a laceration to the forehead.
VS: BP 130/90 mm Hg, HR 90, and RR 25
Management priorities in this scenario can be based on
information obtained by surveying the injured patients at a
distance. Although there may be doubt as to which patient is more
injured, based on the available information, a decision has to be
made to proceed with the best information available at the
time.
(Proceed to the next page for questions related to this
scenario.)
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Triage Scenario IIITrailer-home Explosion and Fire continued
1. Identify which patient(s) has associated trauma and/or
inhalation injury in addition to body sur-face burns, and place a
check in the box next to the patient letter.
Patient A Patient B Patient C Patient D Patient E2. Using the
table provided below,
a. Establish priorities of care in your hospital emergency
department by placing a number (#1 through #5, with #1 being your
highest priority and #5 being your lowest priority) in the space
provided for each patient letter in the column Treatment
Priority.
b. Identify which patient has associated trauma and/or an airway
injury and place a mark in the appropriate column under
Associated.
c. Estimate the percent of body surface area (BSA) burn for each
patient and enter the percent for each patient letter in the column
% BSA.
d. Identify which patient is transferred to a burn center and/or
to a trauma center and place a mark in the appropriate column under
Transfer.
e. Establish your priorities for transfer and enter your
priority number under Transfer Priority.
Patient
AssociatedTreatment
Priority%
BSA
Transfer
Transfer PriorityTrauma AirwayInjury Burn Trauma
A
B
C
D
E
(Proceed to next page for Scenario IV.)
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Triage Scenario IVCold Injury
Scenario:You are in your hospital when you receive a call that 5
members of a doctors family were snowmobiling on a lake when the
ice broke. Four family members fell into the lake water. The doctor
was able to stop in time and left to seek help. The response time
of basic and advanced life support assistance was 15 min-utes. By
the time basic and advanced life support units arrived, 1
individual crawled out of the lake and removed another victim from
the water. Two individuals remained submerged, were found by rescue
divers, and were removed from the lake. Rescuers from the scene
provided the following information.
Patient AThe doctors 10-year-old grandson was removed from the
lake by rescuers. The ECG moni-tor shows asystole.
Patient BThe doctors 65-year-old wife was removed from the lake
by rescuers. The ECG monitor shows asystole.
Patient CThe doctors 35-year-old daughter, who had been in the
lake and was helped out of the water by her sister-in-law, has
bruises to her anterior chest wall.
VS: BP 90 mm Hg systolic
Patient DThe doctors 35-year-old daughter-in-law, who had been
submerged and crawled out of the lake, has no obvious signs of
trauma.
VS: BP 110 mm Hg systolic
Patient EThe 76-year-old retired doctor, who never went into the
water, has no complaints except for cold hands and feet.
1. Establish the priorities for transport from the scene to your
emergency department and provide a brief rationale for your
decisions.
Rationale
Transport priority #1 Patient _____
____________________________________________
____________________________________________
Transport priority #2 Patient _____
____________________________________________
____________________________________________
Transport priority #3 Patient _____
____________________________________________
____________________________________________
Transport priority #4 Patient _____
____________________________________________
____________________________________________
Transport priority #5 Patient _____
____________________________________________
____________________________________________
(Proceed to next page for continuation of Scenario IV.)
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Triage Scenario IVCold Injury continued
2. Upon arrival in the emergency department, all patients should
have their core temperature taken. Briefly, outline your rationale
for the remainder of the primary assessment, resuscitation, and
second-ary survey of each patient.
Patient A: Priority #______:
__________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Patient B: Priority #______:
__________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Patient C: Priority #______:
__________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Patient D: Priority #______:
__________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Patient E: Priority #______:
__________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
(Proceed to next page for Scenario V.)
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Triage Scenario VCar Crash
Scenario: You are the only doctor available in a 100-bed
community emergency department. One nurse and 1 nurses aide are
available to assist you. Ten minutes ago you were notified by radio
that ambu-lances would be arriving with patients from a single
motor vehicle crash. No further report is received. Two ambulances
arrive with 5 patients who were occupants in an automobile
traveling at 60 miles (96 km)/hour before it crashed. The injured
patients are:
Patient AA 45-year-old man was the driver of the car. He
apparently was not wearing a seat belt. Upon impact, he was thrown
against the windscreen. On admission, he is notably in severe
respiratory dis-tress. The prehospital personnel provide the
following information to you after preliminary assessment. Injuries
include (1) severe maxillofacial trauma with bleeding from the nose
and mouth, (2) an angulated deformity of the left forearm, and (3)
multiple abrasions over the anterior chest wall.
VS: BP 150/80 mm Hg, HR 120, RR 40, GCS Score = 8
Patient BA 38-year-old woman passenger was apparently thrown
from the front seat and found 30 feet (9 meters) from the car. On
admission she is awake, alert, and complains of abdominal and chest
pain. The report you are given indicates that on palpating her
hips, she complains bitterly of pain and fracture-related crepitus
is felt.
VS: BP 110/90 mm Hg, HR 140, RR 25
Patient CA 48-year-old male passenger was found under the car.
You are told that on admission he is confused and responds slowly
to verbal stimuli. Injuries include multiple abrasions to his face,
chest, and abdomen. Breath sounds are absent on the left, and his
abdomen is tender to palpation.
VS: BP 90/50 mm Hg, HR 140, RR 35, GCS Score = 10
Patient DA 25-year-old hysterical woman was extricated from the
back seat of the vehicle. She is 8 months pregnant and complains of
abdominal pain. Injuries include multiple abrasions to her face and
anterior abdominal wall. You are told that her abdomen is tender to
palpation. She is in active labor.
VS: BP 120/80 mm Hg, HR 100, RR 25
Patient EA 6-year-old boy was extricated from the floor of the
rear seat. At the scene, he was alert and talking. He now responds
to painful stimuli by only crying out. Injuries include multiple
abrasions and an angulated deformity of the right lower leg. There
is dried blood around his nose and mouth. You are told that his
vital signs are:
VS: BP 110/70 mm Hg, HR 180, RR 35
(Proceed to next page for questions related to Scenario V.)
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Triage Scenario VCar Crash continued
1. Outline the steps you would take to triage these 5
patients.
_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
2/3. Establish your patient priorities by placing a number (#1
through #5, with #1 being your highest priority and #5 being your
lowest priority) in the space provided next to each lettered
patient. In the space provided here, also briefly outline your
rationale for prioritizing these patients in the manner you
did.
Priority #_____ Patient
ARationale:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Priority #_____ Patient
BRationale:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Priority #_____ Patient
CRationale:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Priority #_____ Patient
DRationale:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Priority #_____ Patient
ERationale:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
(Conclusion of Triage Scenarios)
