Scene Size-up

Courtesy of Bonnie Meneely, EMT-P

Overview
Relationship of time to patient survival
• Actions on scene

Steps of Scene Size-up

Two basic mechanisms of motion injury
• Mechanisms and settings

Two most common forms of penetrating injury

• Mechanisms and extent

Assessment criteria for falls

• Anticipated injuries
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Overview
Blast injury factors related to assessment
Collisions in motor-vehicle crash
• Potential injuries related to vehicle damage

Common motor-vehicle crash forms

• Lateral-impact compared to head-on collision
• Potential head-on collision injuries
• Proper and improper use of safety devices
• Potential rear-end collision injuries
• Higher mortality rate for ejection

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Trauma

For severely injured patients,

survival is time-dependent!

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Trauma Survival
Golden Hour
• From moment of injury
• To definitive treatment

EMS “platinum 10 minutes”

Assessment and management

• Every action must have lifesaving purpose
• Organized, detail-oriented, selective, rapid

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Trauma Care
Teamwork is important!
You must know:
• What you can handle and what you can’t
• What you should handle and what you shouldn’t
• When to stay and when to leave
• Fastest route there and fastest route away
• What to do, what not to do, and when to wait

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Scene Size-up
A critical part of trauma assessment
• Anticipate what you will find at scene
• Anticipate equipment and resource needs
• Form a plan of approach
• Be prepared to modify that plan

Failure to size-up can jeopardize lives.

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Scene Size-up
First step in BTLS Primary Survey
BTLS Patient Assessment

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Scene Size-up

1. Standard precautions
2. Scene safety
3. Initial triage (total number of patients)
4. Need for more help or equipment
5. Mechanism of injury

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Standard Precautions

Personal protective equipment is

always needed at trauma scenes.

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Scene Safety
Ambulance positioning
• Safe place to park
• Facing away from scene

Windshield survey
• Threats to you
• Threats to/from patient Courtesy of Bonnie Meneely, EMT-P

• Threats to/from bystanders

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Initial Triage
Total number of patients
• Call for backup
• Medical command
• Initiate MCI protocols
• Any more patients?

Courtesy of Bonnie Meneely, EMT-P

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Need for More
Essential equipment
• Carry to scene for time efficiency
• Change gloves between patients

Additional resources
• Call early
• Relay what to expect, where to respond

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Mechanism of Injury
Energy follows physics laws.
• Injuries present in predictable patterns

High-energy at risk for severe injury.

• Consider injured until proven otherwise

Factors to consider:
• Direction and speed of impact, patient kinetics
and physical size, signs of energy release

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Basic Motion Mechanisms
Blunt injuries Penetrating injuries
• Rapid forward • Projectiles
deceleration
• Knives
• Rapid vertical
• Falls upon objects
deceleration
• Blunt instrument
energy transfer

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Motor-Vehicle Collisions
Each collision is three collisions:
Machine
1 Collision
2 Body
Collision
3 Organ
Collision

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Other Collisions
Secondary collisions
• Objects are missiles
at original speed

Additional impacts
• Vehicle collides
with another object
• Other vehicles collide
with original vehicle

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Clues to Injury
Deformity of vehicle
• What forces were involved in collision?

Deformity of interior structures

• What did patient hit?

Deformity or injury patterns on patient

• What anatomic areas were hit?

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Common Collisions
Common types
• Head-on
• Lateral-impact (T-bone)
• Rear-impact
• Rollover
• Rotational

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Head-on Collision
Windshield injuries
• Brain, soft-tissue injury,
cervical spine

Steering wheel injuries

• Traumatic tattooing of skin

Dashboard injuries Courtesy of Bonnie Meneely, EMT-P

• Face, brain, cervical spine,

pelvis, hip, knee
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Lateral-Impact Collision
Similar to head-on
with lateral energy
• Not easily predicted
• Consider organ damage

Check impact side

• Head, neck, upper arm,
shoulder, thorax, Courtesy of Bonnie Meneely, EMT-P

abdomen, pelvis, legs

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Rear-Impact Collision
Posterior displacement
• Rapid forward deceleration
also possible

Headrest position
• Hyperextension injuries

Damage back and front Courtesy of Bonnie Meneely, EMT-P

• Deceleration injuries

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Rollover Collision
Multiple impacts
• Multiple directions
• Multiple injuries
Axial-loading injuries
• Spine injury
Ejection Courtesy of Bonnie Meneely, EMT-P

• Chance of death
increases 25 times

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Rotational Collision
Head-on, lateral-impact
combination
• Converts forward motion
to spinning motion

Windshield, dashboard,
steering wheel, side
• Same possible injuries
of both mechanisms

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Occupant Restraint
Lap belt Air bags
• Clasp-knife effect • First impact only
• Abdomen • Always “lift and look”
• Lumbar spine

Three-point restraint
• Cervical spine
• Clavicular fracture

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Tractor Accidents
One-third of farm fatalities
• Side overturns 85%
• Likely to throw clear
• Rear overturns 15%
• Likely to entrap or crush

Common injuries
• Crush injuries Courtesy of Roy Alson, MD

• Thermal and chemical burns

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Small-Vehicle Crashes
Small vehicles
• Motorcycles
• All-terrain vehicles
• Personal watercraft
• Snowmobiles

Factors
• Protective gear
• Additional impacts

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Pedestrian Injuries
Mechanism
• Primary collision
• Additional impacts

Common injuries
• Severe internal injuries
and fractures
• Adult: bilateral leg, knee Courtesy of Bonnie Meneely, EMT-P

• Child: pelvis, torso

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Falls
Vertical deceleration
• Distance of fall
• Anatomy impacted
• Surface struck

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Penetrating Injuries
Knife-wound severity
• Anatomic area penetrated
• Fourth intercostal space may
be chest and abdomen
• Length of blade
• Angle of penetration

Stabilize impaled object

• Minimize external movement

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Penetrating Injuries
Firearms
• Type of weapon
• Low-velocity
• High-velocity
• Caliber
• Missile size
• Bullet construction
• Tumbling/yaw Courtesy of Roy Alson, MD

• Distance traveled

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Penetrating Wounds
Entry wound
• Smaller
• May be darkened, burned

Exit wound
• One, none, or many
• Larger
• May be ragged

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Penetrating Wounds
Internal wound
• Tissue contact damage
• High-velocity transfer of energy
• Shock waves
• Temporary cavity
• Pulsation of temporary cavity

Damage proportional to tissue density

• Highly dense tissue sustains more damage

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Blast Injuries
Primary
• Initial air blast
Secondary
• Material propelled
Tertiary
• Impact on object
Quaternary Courtesy of Roy Alson, MD

• Dispersed hazardous

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Caution

Do not approach until

Scene Size-up is complete!

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Summary
Time is critical; teamwork is essential.
Scene size-up can be lifesaving.
Mechanism of injury:
• An aid to predict injury
• Part of overall management of trauma patient

Record scene and mechanism findings.

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Discussion

Photo © Jeff Forster

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