LEARNING OBJECTIVES

Upon completion of this course, you will be able to:

• Recount the cost to society of motor vehicle crashes.
• Evaluate the extent to which occupant protection systems reduce death and injury.
• Explain how different impacts produce various types of injuries.
• Identify the elements of a good scene size-up.
• Demonstrate the assessment of a patient with a traumatic mechanism of injury.
• Discuss the management of injuries to specific areas of the body.

With the invention of the internal combustion engine and the pneumatic tire in the late 1800s, automobiles began traveling the roads of Europe and the United States—and crashes quickly followed. In 1885 Carl Benz forgot to steer and crashed into a wall, blazing the way for a major cause of traumatic injury (Duncan & Meals, 1995). The first recorded crash in the United States occurred in 1896 when a car crashed into a bicyclist (NHTSA, 2006a).

Death and injury from motor vehicle crashes continues to be a significant health problem. In 2005, 43,443 people were killed in motor vehicle crashes and about 2.7 million were injured. At least half of the fatalities were to unrestrained occupants (NHTSA, 2005a). Of these, many were bicycle injuries and many more were pedestrians. These crashes cost society its youngest and most productive members because they are the leading cause of death for ages 3 to 34 (NHTSA, 2005a).

The costs to society due to crashes are immense. Crashes cost over $230 billion in 2000 and about 75% of these costs were borne by those not involved in the crash. (NHTSA, 2006b). Crashes claim lives, and consume healthcare resources. They cost productivity and cause upheaval in many lives. From 1975 to 2005, an estimated 211,000 lives were saved by seat belts. If seat belt use were at 100%, almost 345,000 more would have been saved. (NHTSA, 2005a).

PREVENTION AND RESTRAINT LAWS

Proper restraint use is the surest and simplest way to prevent death and injury due to motor vehicle crashes. All but one state has an adult seat belt law, but many are secondary laws, meaning that law enforcement cannot ticket for a seat belt violation unless the vehicle was stopped for another offense. Primary laws, in which a vehicle can be stopped for a seat belt violation, have been shown to increase the use of seat belts and lower fatality rates. These laws are most effective when combined with education and enforcement efforts (NHTSA, 2006b).

Air bags were initially intended to protect unrestrained occupants but they offer much more protection when used with a seat belt and are now considered a secondary restraint. They are effective in preventing death and injury but they are very powerful and must be used properly. Air bags can cause serious injury to an occupant who is too close to the module when it deploys. This is especially true for unrestrained or out-of-position children. Rear-facing child restraints must never be used in the front seat because the extreme forces of deployment are transferred to the child's head. The impact is usually fatal.

Child restraint devices are effective in preventing injury. Properly restrained infants show a 71% reduction in injury and restrained toddlers a 54% reduction in injury (NHTSA, 2007a). Children are restrained more often than adults, but unrestrained adults are more likely to leave children unrestrained (NHTSA, 2006b). Booster seats protect children who have outgrown their child restraints but are not yet large enough for an adult seat belt. Laws requiring booster seats are becoming more common. Children restrained in a booster with a lap shoulder belt have a 59% reduction in serious injury over lap shoulder belts alone (Miller et al., 2006).

For riders of motorcycles, bicycles, and all-terrain vehicles (ATVs), helmets offer a significant reduction in fatalities and head injury; head injury is the leading cause of death for motorcyclists. Unhelmeted motorcyclists are 40% more likely to die in a wreck and 15% more likely to suffer a nonfatal head injury than those who wear helmets.

Motorcycle helmet use saved an estimated 1546 lives in 2005, and as many as 728 more could have been save if all motorcyclists had worn helmets (NHTSA, 2005b). Helmet use also saved an estimated $19.5 billion from 1984 through 2002. If all motorcyclists had worn helmets during the same period, an additional $14.8 billion could have been saved (NHTSA, 2007c).

Bicycle helmet use remains between 20% and 25%, despite the fact that 70% of fatalities involve head and brain injury. These injuries cost about $8 million annually. Helmets are inexpensive and are up to 88% effective in reducing brain injuries. Children under 14 account for 16% of deaths and young adults another 24%, making this costly in terms of lost productivity (NHTSA, 2007c).

For ATV users, helmets have been shown to reduce nonfatal head injury by up to 64% and mortality by 42% (Aitken et al., 2004).

INJURY PATTERNS

Before looking at injury patterns, it is helpful to review some of the physics involved, notably Newton's First Law of Motion. It states that an object in motion will remain in motion until acted on by another force. Thus, a vehicle in motion will keep moving until something—a tree, another vehicle, the brakes, or some other force—causes it to slow down, stop, or change direction. When such a force is applied, people in the vehicle will continue to move at the original speed until a force such as the seat belt, the steering wheel, or the windshield causes them to slow down, stop, or change direction. Even then, the organs of the body will continue in motion until slowed or stopped by the bones and other supporting structures within the body.

The forces on the vehicle, the body, and the organs are applied in sequence. This sequence is rapid if the vehicle strikes a fixed object, and much less so during a controlled stop. If this sequence were to be observed in slow motion, the body and the organs would seem to move toward the point of impact. This is important because it provides clues as to where to look for injury.

Remember that it is not the change in speed that causes the damage but how fast the change occurs. Going from 60 mph to a full stop may do no damage if it happens over a few seconds. But if the change occurs over a few milliseconds, a much greater force is involved, and it can be deadly. Anything that increases the stopping time will decrease the forces involved. This is the reason for such safety features as crush zones in the vehicle's front end and steering wheel and the stretch in the seat belt.

Frontal Impacts

About 51% of crashes and 61% of fatalities involve frontal impact (NHTSA, 2005a). As most vehicle travel is in a forward direction, these numbers are not surprising. Even in a side- or rear-impact crash, one of the vehicles sustains a frontal impact. Ideally, in a frontal impact, the front bumper strikes the other vehicle or object; as the front end crushes, the stopping time of the vehicle is increased, thus reducing the forces transferred to the occupants. The airbag and seat belt further increase the stopping time of the occupant, reducing the forces on the organs.

Damage to the passenger compartment can provide clues to suspected injuries. Emergency medical responders look at the windshield. Is it intact? If not, the shape of the damage will provide clues as to whether it was it caused by a head, another body part, or a loose object in the vehicle. Look for hair, skin or blood imbedded in the glass. The impact of a head will show a classic star or spider web pattern. A more severe impact will cause the broken segment to bulge out. A hand striking the windshield will cause a smaller, often elongated, break.

Consider the airbag itself as a source of windshield damage, especially on the passenger side. Lift up the airbag and look at the steering wheel. Is it bent? If so, assess the occupant for chest and abdominal injuries. Look at the lower dashboard. Are there dents or cracks? If so, look for knee, hip, and femur injuries. This is especially common when the seat back is reclined too far. Even if the seat belt is used, the occupant may slide underneath it and strike the dash. Look at the floor and firewall. Damage there can point to foot and lower-leg injuries.

Side Impacts

About 27% of passenger cars involved in crashes sustain a side impact, with the left side involved slightly more often than the right. Side impacts are also responsible for about 27% of fatalities (NHTSA, 2005a). The side of the vehicle has no crush zone, so forces may be transferred directly to the occupant. Look for intrusion into the passenger compartment. The greater the intrusion, the greater is the likelihood of injury.

At what level was the impact? Impact low on the door may lead to pelvic injuries. This is especially likely if there is a fixed center console. Impact from a taller vehicle may cause damage higher up on the door. Was it at the level of the chest, shoulder, or even the head? Did side airbags deploy? These may reduce the forces to the head and torso. At what level is the armrest? If the main force came from the same level, it may have put severe forces on the abdomen.

Rear Impacts

Rear-end crashes tend to be less severe than other types. They account for 21% of crashes and only 6.5% of fatalities (NHTSA, 2005a). In read-end crashes, typically only one vehicle was moving, or both vehicles were moving in the same direction; therefore, the change in speed was less. Try to determine whether the vehicle struck from the rear was stopped or moving. If it was stopped, was the brake applied? If the brake was set, the energy was transferred from the moving vehicle to the struck vehicle and then to the occupant.

The occupant is thrown forward, causing the neck to hyperflex. This can cause compression of the vertebral bodies and stretching of the posterior ligaments. As the person rebounds, the head may hyperextend, causing anterior neck injuries. This rapid flexion and extension is commonly called whiplash. These injuries can be much less severe if the head rest was properly placed at the occipital level to prevent the hyperextension.

Driver experiencing whiplash. The head snaps back without the restraint of the headrest and the neck hyperextends. (Illustration by Jason M. McAlexander, MFA. Copyright © 2007 Wild Iris Medical Education.)

Try to determine whether whiplash has occurred before extrication. Look at the seat back. How far is it reclined? If the seat back was upright before the crash and it broke, this indicates a severe wreck and a high risk for spinal injury. Some younger occupants routinely recline the seat back. This can cause the occupant to slide under the seat belt and strike the dashboard with the knees.

Rollover Injuries

Rollovers produce extremely variable injury patterns. They may involve one or more impacts with another vehicle or object, or the rollover may be the only event. The critical variable is restraint use. Properly restrained occupants often have minor injuries or are uninjured. An unrestrained occupant in a rollover has a high risk of ejection. With nothing to help absorb the energy of the impact on the human body, an ejected occupant is much more likely to be killed or seriously injured. Side-curtain airbags, because they do not deflate quickly, may reduce the risk of ejection.

Motorcycle Injuries

Motorcycles were involved in about 1% of crashes but almost 8% of fatalities in 2004 (NHTSA, 2005a). As the motorcycle itself offers almost no protection, the occupant is subject to severe forces similar to those experienced by an ejected automobile or truck occupant. Head injury is common, especially in the absence of a helmet. There may be multiple fractures and large, painful abrasions with imbedded debris (road rash).

Bicycle Injuries

In 2005, 784 bicyclists were killed and nearly half a million were injured (NHTSA, 2007c). As with motorcycles, the bicycle offers no protection. However, because bicycles do not travel as fast or weigh as much as a motorcycle, the vehicle itself does not generally crush or pin the operator. Most common injuries may be extremity fractures and soft-tissue injuries.

All-Terrain Vehicles (ATVs)

All-terrain vehicles were initially designed as work vehicles but are now commonly used as recreational vehicles. They have a very high center of gravity and require considerable skill to operate safely. Despite legislation and education campaigns, children continue to operate them. While children account for only 14% of operators, they account for 35% of deaths, a risk 4.5 to 12 times greater than for adults. Injury and death is associated with ATV use on public roads and with lack of a helmet.

Production of three-wheeled ATVs was banned during the 1980s due to high injury rates, but injuries from four-wheeled ATVs continue to increase (Aitken et al., 2004). Fractures, wounds, and head injuries are commonplace.

Pedestrian Injuries

In 2005, 4,881 pedestrians were killed and about 64,000 were injured (NHTSA, 2005a). Injuries result from being struck by a vehicle as well as from striking the road or other objects upon landing. With nothing at all to absorb the impact, injuries can be severe. Location of injuries will depend on the relative height of the pedestrian and the vehicle. Children have more head and torso injuries, while adults have more leg injuries.

Injury reduction depends mostly on education and engineering. Teaching children to walk and cross streets safely will reduce injuries. Better crosswalk markings and signals at intersections increase safety. Many vehicle manufacturers are making efforts to design bumpers and front ends that minimize injury to pedestrians.

School Bus Injuries

With only 134 fatalities during 2005, school buses remain the safest method of travel. Of these fatalities, only ten involved drivers or passengers on the bus. The remainder were pedestrians, cyclists, and occupants of other vehicles (NHTSA, 2005a). School bus safety is due to their relative size and high visibility, as well as to a passive restraint system known as compartmentalization. With this restraint system, the passengers are protected by high, padded, energy-absorbing seat backs, which are very effective in reducing injury.

SCENE SIZE-UP

Scene size-up is an assessment of the scene and surroundings that may yield clues to the nature and mechanism of the patient's injuries. Ideally, scene size-up begins when you get the call. What can the dispatcher tell you about the call? Keep dispatch information in mind but don't have tunnel vision once you arrive on scene.

One detail that the caller didn't relate can change your overall understanding of the incident. Is it a busy downtown intersection or stretch of rural highway that is a frequent site of severe crashes? Do you need extra resources started or placed on standby? Consider the weather and traffic. Will it complicate the scene or delay arrival of resources? In some areas you may need to consider hospital availability. Local protocol may dictate the hospital to which a trauma patient may be transported.

A good scene size-up quickly identifies anything that makes the scene unsafe. Again, this begins at dispatch. If the scene is not safe, don't go in. If you get there and the scene becomes unsafe, get out. Spills and leaks may only be slippery—or they may be toxic. The presence or suspected presence of toxic substances is an opportunity for rescuers to become victims.

If you suspect that toxic materials are present, immediately summon Hazmat support. Emergency medical personnel do not enter a Hazmat area. If possible, park well out of the way and have the patient brought to you once they have been properly decontaminated. Watch for power lines, traffic, or even altercations among those involved.

Count the number of vehicles and get a quick look at the nature and extent of the damage. Look for your patients. Are they trapped in the vehicle or up and walking? How many are there? Order extra resources early.

Consider your access and exit routes, not just for your safety but for practical purposes. As additional resources arrive, you don't want to be trapped with a critical patient needing hospital care.

Will the patients need to be protected from extreme weather conditions? Who else is at the scene? Are they potential patients? Don't let bystanders become victims of sightseeing motorists! Does someone need to deal with the media? This is best left to a supervisor or public information officer who has no patient care responsibilities

Expect that you will have primarily traumatic complaints, but use caution and be open to changing your mind. A car wreck may have been preceded by a stroke or heart attack. Signs of trauma may be subtle if the patient is unconscious.

You should have started assessing mechanism of injury (MOI) of a trauma patient prior to patient contact. Determine the number of patients and call for additional resources, if needed, before beginning any patient care.

What can the scene tell you about the injuries to expect? Where is the damage on the car and how severe is it? Do not neglect these observations because they provide valuable information that will be useful to the receiving facility later. The trauma surgeon cannot see the bent steering wheel or broken windshield but they will know what injuries to suspect if you give an accurate report. Take spinal precautions early.

INITIAL ASSESSMENT

When you are ready to begin care of a specific patient, start the initial assessment with a general impression of the patient. Does the patient appear seriously injured or not? Assess mental status using the AVPU scale. Go forward with the ABCs while taking spinal precautions:

• Assess the airway and use a jaw thrust if needed. If you can't open a trauma patient's airway with a jaw thrust, you may have to use the head tilt–chin lift method. Are there signs of an obstructed or partially obstructed airway or noisy breathing? If you need to clear the airway, first try repositioning. Use suction as needed and place an adjunct if tolerated by the patient. If the airway is clear, can the patient maintain it on his or her own? If not, insert an airway adjunct.
• Check for adequate breathing. If the patient is responsive but not breathing adequately, give high-flow oxygen and be prepared to assist ventilation if needed. If the patient is unresponsive and breathing adequately, make sure they can keep their airway open and use an adjunct if they cannot. Give high-flow oxygen. If the patient is unresponsive and not breathing adequately, place an adjunct and provide ventilation with a bag-valve-mask device using high-flow oxygen.
• Assess the patient's circulation. A patient who is responsive and/or breathing adequately has a pulse. If the patient is unresponsive and not breathing adequately, feel for a pulse, using the carotid for an adult and the brachial for an infant. Check for at least 5 seconds but no more than 10 seconds. If you cannot feel a pulse, follow your local protocol.

Some systems consider cardiac arrest due to trauma incompatible with life and do not attempt resuscitation. If any doubt exists, begin compressions. If the patient has a pulse, are they perfusing well? Can you feel a radial pulse as well as a carotid pulse? Look for major bleeding and control it. Assess the patient's skin, noting color and condition. Check capillary refill. It should be less than 2 seconds in adults and children.

With the information you have gathered, decide whether you have a priority patient. Priority patients are transported immediately. BLS units should request ALS back-up if it is available without a delay in transport time. Any problem you found in your initial assessment indicates a priority patient. This includes:

• Poor general impression
• Unresponsive or altered mental status
• Airway compromise
• Inadequate or difficult breathing
• Inadequate perfusion or shock
• Including cardiac arrest
• Severe bleeding that can't be controlled

Any patient who has been ejected from a vehicle, was in the same vehicle as someone who died, or required a long extrication should also be considered a priority patient no matter how minor their injuries. Also consider age. The very young and very old have limited compensatory mechanisms and may deteriorate quickly with seemingly minor injuries. Older adults may have decreased pain perception that can mask the severity of an injury. With priority patients, a detailed exam can be done en route. If the patient is not a priority, you can proceed with a focused history and physical exam at the scene.

FOCUSED HISTORY AND PHYSICAL EXAMINATION

The focused history and physical examination will give you more information about the patient's condition and guide your treatment decisions. The history is ideally obtained from the patients. If they cannot answer your questions, some information may be obtained from family or bystanders.

Use the mnemonic SAMPLE to assist you in getting a complete history. Ask about:

• Signs and symptoms of the present illness or injury
• Allergies
  Medications
• Past medical history that may be pertinent to this incident
• Last oral intake
• Events leading up to the injury

The events leading up to the injury are handled a bit differently at the scene of a car crash. Ask five people what happened and you will get five different answers. Let the wreck tell you. Take the time to walk completely around the vehicles and look at the damage. Where was the greatest impact? Look for signs of multiple impacts, especially if more than two vehicles were involved. Look at the extent of the exterior damage. Remember that the front of newer cars is designed to crush easily. This disperses energy and reduces injury to the occupants. Interior damage will tell more about what injuries to expect.

Look at the windshield. Is it intact? If not, what caused the damage? Was it a head, a hand, or another object such as an airbag cover? Did air bags deploy? Were they frontal or side airbags? Remember that airbag sensors detect very rapid deceleration. If road conditions or the relative weights of the vehicles are right, energy will be dispersed and the airbags will not deploy. Look at the steering wheel for signs of damage.

For a side impact, look at the door. Was there intrusion into the passenger compartment? Look for damage to the lower dashboard. This can point to knee, femur, and hip fractures. What kind of restraint was used? Does the evidence match what the patient tells you? If not, be sure to document both very carefully.

A newer car may have seat belt pre-tensioners. This device will cause the seat belt to tighten up right before impact. Once it has deployed, the seat belt will no longer move in or out of the retractor. Therefore, a seat belt that lies loosely across the seat was worn. A seat belt tight in the retractor was not in use.

If the car was an older model with automatic shoulder belts, ask whether the lap belt was worn. A shoulder belt worn without a lap belt allows the occupant to slide under the belt. Look for leg injuries. If children are involved, note whether child restraints were used and, if so, what kind. If the seat belt was used, ask what the child did with the shoulder belt. Many put it under their arm or behind them. If worn under the arm, the rib cage takes the impact. Look for serious chest injuries. Children who wore the shoulder belt behind them or used a lap belt alone were at very great risk for a serious set of injuries know as seat belt syndrome.

Children have small pelvic bones and tend to slouch, which allows the lap belt to ride up over the abdomen. Upon impact the upper body flies forward and jackknifes over the belt. This causes serious internal injuries and fractures of the lumbar spine. There may also be head and facial injuries from striking the seat back, dashboard, or even the child's own legs. Was the impact from the rear? Look for the use of head restraints. Note the condition of the seat back. If it was flung back, the impact was very severe and fractures should be suspected.

For a trauma patient, most serious injuries will be found during the initial assessment and immediate life threats should be treated as soon as they are found. Anyone who has sustained a major impact should have a rapid trauma examination to make sure no serious injuries have been overlooked. For a minor wreck, the examination can be limited to the area injured.

It is important to develop a systematic approach to any assessment. This helps to ensure a complete, organized, and efficient exam. Be sure to maintain spinal stabilization during the exam. If the patient is responsive, ask what hurts or what doesn't feel right. Assess each major area for signs of injury. The mnemonic, DCAP-BTLS may be helpful. Look and feel for any Deformities. Note Contusions, Abrasions, Bruises or Penetrating injuries. These may indicate internal injuries. Look very carefully. A very small penetrating wound may be easy to miss but there may be severe internal damage. Note any Burns, Tenderness, Lacerations, or Swelling.

For most adults, begin by examining the head. In addition to the above signs of injury, look for blood or clear fluid coming from the ears or nose. When you assess the neck, look for the large veins on either side of the neck. The jugular veins should not be distended if the patient is supine. Apply a cervical collar. Assess the chest and watch it rise and fall as the patient breathes. Look for unequal chest rise, or paradoxical motion; this is when one segment of the chest rises as the rest falls and falls as the rest rises.

Listen to breath sounds in the mid-clavicular and mid-axillary lines bilaterally. Note absent, unequal, or noisy breath sounds. As you assess the abdomen, palpate in all four quadrants and note whether it is firm or soft. Note any distention or palpable masses. Gently compress the pelvis and note any motion or tenderness. Assess all extremities and check for distal pulses, movement, and sensation. While maintaining spinal stabilization, log roll the patient and assess the back. Assess baseline vital signs.

DETAILED PHYSICAL EXAMINATION

A detailed physical examination may be performed on some trauma patients. It is used to gather even more specific information about the patient's condition and is generally not indicated for a minor injury. If the patient has critical injuries, multiple injuries, or a complex ongoing examination with multiple concerns, it will not be performed, nor will it be performed on short transports where time does not allow.

If your patient is fairly stable despite a major mechanism of injury and you have a long transport time, it may be performed. The same systematic approach is used, but it is slower and more thorough. This is especially true with the head. Using the DECAP-BTLS approach, inspect and palpate the scalp. Palpate the facial bones and look at the face for symmetry or swelling. Recheck the ears for drainage. Assess the eyes for discoloration, foreign bodies, or blood. Check the pupil's size and reactivity to light. Assess the nose for drainage or bleeding. Assess the mouth for loose or missing teeth, swollen or lacerated tongue, or foreign bodies. Assess the neck again looking for distention of the jugular veins.

Assess the chest for bruising, wounds, or paradoxical motion. Check for crepitus, the grating sensation that is felt when broken bone ends move against each other. A sensation similar to crepitus can be felt in the chest or neck as a result of air leaking from a punctured lung into the soft tissue. This is a serious finding that may not have been apparent on the initial examination.

Reassess breath sounds. Reassess the abdomen; is it firm or soft? Are any masses or pulsations palpable? Check the pelvis for motion or crepitus. Assess all extremities for injury as well as distal pulses, movement, and sensation. Check the back if you can do so without compromising spinal stabilization.

ONGOING ASSESSMENT

A good ongoing assessment is not an action but a continuous process that lasts for the length of the patient encounter. Once the focused and detailed examinations are completed, go back and repeat your initial examination. If the patient is responsive and stable, you are doing this as you converse with the patient. The patient responses show that they have an airway and a pulse and the pattern of response gives an indication of their mental status and how well they are breathing.

For the unstable or unresponsive patient, go back and repeat the steps of the initial assessment at least every five minutes. Repeat and record vital signs. Repeat a focused examination if indicated. Swelling may cause a correctly applied splint to become too tight en route. Make sure that your oxygen delivery and artificial ventilations are adequate. Don't arrive at the hospital ventilating from an empty oxygen cylinder! Check dressings to make sure bleeding is controlled. Use the ongoing assessment to re-establish priorities. Once major bleeding is controlled, it may be time for a splint somewhere else.

SPECIFIC INJURIES

For most patients involved in a motor vehicle crash, you should consider spinal precautions right away. Seriously injured patients should have oxygen. If your scope of practice permits, place the patient on a cardiac monitor and start an IV line. If you are treating a priority patient, these things are done en route to the hospital.

Head Injuries

Motor vehicle crashes are the most common cause of head injuries. Even if patients survive head injuries, they can have permanent, devastating consequences. These patients often require very costly, lifelong care. Mental status changes may be the earliest sign of serious injury. Therefore, initial and ongoing assessment of mental status is the single most important aspect of the overall assessment of the trauma patient.

Local protocol will dictate whether the Glasgow Coma Scale, Revised Trauma Score, or some other method is used. Try to determine whether the patient lost consciousness. If so, how long after the wreck did it occur and how long did the patient remain unconscious? Determine whether they are oriented to person, place, time, and situation. Do they remember the wreck and what led up to it?

If the patient is unconscious, look for posturing, which is a serious sign. Look for any open wounds or deformities. As you obtain a SAMPLE history, pay attention to any blood thinners the patient may be taking. These could include coumadin or warfarin, aspirin, or Plavix. A patient taking one or more of these medications may have a severe head injury from a minor impact.

Try to determine whether alcohol use is present because it increases the risk of head injury and may mask or mimic some signs. Treat patients with significant head injury as though they also had a spinal injury. Head-injured patients should receive oxygen. How much is currently under debate. High-flow oxygen causes vasoconstriction and may reduce swelling in the brain; however, the decreased perfusion can also worsen a head injury. Follow your local protocol.

Be prepared to control the airway. Children with a head injury will usually vomit. In adults, vomiting suggests a more severe injury. Have suction available. Be prepared to assist ventilations if needed. Monitor vital signs. Increasing blood pressure and decreasing pulse may indicate a rise in intracranial pressure. Watch for seizures. Document timing and appearance and treat according to local protocol.

Spinal Injuries

As with head injury, spinal injures can have devastating outcomes, and motor vehicle crashes are the most frequent cause. Any patient with significant mechanism, neck or back pain, head injury, or altered mental status should be assumed to have a spinal injury and precautions are taken from the outset of assessment and care.

Gently take control of the cervical spine and encourage the patient to remain still. Ask about pain and gently palpate for tenderness or deformity before placing a cervical collar. If the patient is still seated in the vehicle, consider the use of an extrication device. This should be deferred if the patient or the scene is too unstable to allow the necessary time.

Palpate the spine as you move the patient to a long spine board, either during extrication or by log rolling a supine patient. Spinal injury cannot be ruled out just because a patient is up and walking; use a standing long board technique for these patients. Document pulse movement and sensation in all extremities before and after applying an immobilization device. Monitor vital signs. Patients with spinal injury may develop hypotension without tachycardia due to spinal shock.

Spinal immobilization is not without complications. Prolonged time on a long spine board can cause back pain or pressure sores. This has caused some to rethink the rule to immobilize all patients with a traumatic injury. Some systems are using a checklist to identify patients at low risk of spinal injury and thus defer immobilization. This must be monitored closely by medical direction and should only be done according to local protocol.

Chest Injuries

A broken steering wheel or severe intrusion near the patient should prompt you to look for chest injuries. Initial assessment of the chest includes palpation of the chest wall and auscultation of the lungs on both sides. Respiratory distress may be apparent immediately or may develop over time. Give oxygen early and be prepared to assist ventilations. Identify any major bleeding or penetrating chest wounds; these should be sealed as soon as they are found.

During the detailed examination, assess the chest for paradoxical motion. Look for bruising and accessory muscle use. Also feel for crepitus. Reassess breath sounds. A patient with severe blunt or penetrating chest trauma may develop a tension pneumothorax. These patients will have progressive shock and respiratory difficulty. Lung sounds will be decreased or absent on the affected side.

Tracheal deviation away from the affected side is a late sign and should not be relied on too heavily. If it is within your scope of practice, needle decompression can be lifesaving. If an open chest wound has been sealed, releasing the seal may also relieve the pressure.

Abdominal Injuries

Impact with the steering wheel, intrusion from a side impact, and improper use of seat belts can all lead to abdominal injuries. A lap belt that is allowed to ride up over the hips or is used without a shoulder belt can cause severe abdominal injury, especially to children who are too small for a seat belt.

Inspect and palpate the abdomen. Is it firm or soft? Are any masses or pulsations palpable? Look for bruises, abrasions, or open wounds. Check the pelvis for pain, motion, or crepitus. Reassess often. Patients with abdominal injuries may develop signs of shock very suddenly. If there is a large open wound with protruding abdominal contents, do not attempt to push the contents back inside. Instead, cover the area with a moist sterile dressing.

Extremity Injuries

With few exceptions, extremity injuries are not life threatening. They can cause severe disability, and they can be spectacular enough to distract attention from more serious injury. They should be treated only when until serious conditions have been addressed. Most priority patients have splints and dressings applied en route to the hospital. Severe bleeding should have been controlled in the initial assessment.

Bilateral femur fractures can cause severe internal bleeding, and shock should be expected in these patients and well as any patients with multiple long-bone fractures. Amputated parts should be retrieved at the scene if it does not delay transport. Wrap them in moist sterile dressings and place in a plastic bag, which is then placed in ice water or on a cold pack. Never place the part itself directly on ice!

Angulated fractures are ideally splinted in the position in which they are found but this may hinder extrication. Some systems allow analgesics to be administered for isolated extremity injuries. Follow your local protocol.

CONCLUSION

Preventing death and injury due to motor vehicle crashes involves many people and numerous approaches. The strategies are often categorized into the four E's:

• Engineering addresses the design of the roadway and signs.
• Enforcement deals with the laws and encouraging them to be observed.
• Education makes information on safe road use practices available.
• EMS. Prompt and appropriate treatment of individuals involved in a crash can significantly reduce disability and mortality. It is up to us to do the best we can for every patient.

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