Trauma: Musculoskeletal, Burns, Head, Spine, and Chest

Trauma: Musculoskeletal, Burns, Head, Spine, and Chest

Trauma calls demand rapid, organized assessment. Your priorities never change: scene safety, BSI/PPE, life threats first. Within that framework, this lesson covers the hands-on skills tested on the NREMT and performed on every trauma response.

Musculoskeletal Injuries

Bones break and joints dislocate from direct force, indirect force, or twisting. Signs and symptoms include pain, swelling, deformity, crepitus, point tenderness, and loss of function. Never forget the six Ps of vascular compromise: Pain, Pallor, Pulselessness, Paresthesia, Paralysis, and Pressure. Assess distal pulse, motor function, and sensation (PMS) before and after every splinting procedure — this is a critical step on the NREMT skill sheet.

Splinting principles: Immobilize the joint above and the joint below the injury. Pad all rigid splints to prevent pressure injuries. Apply traction splints only for isolated mid-shaft femur fractures; never use them for hip fractures, knee injuries, or injuries involving the lower leg or ankle. The Hare and Sager are the two traction splint designs you will use in lab. Apply mechanical traction gradually until pain and muscle spasm ease. Recheck PMS after application. Open fractures require sterile dressings over exposed bone before splinting. Straighten angulated fractures with gentle traction only when PMS is absent distal to the injury or when transport will be significantly delayed — follow local protocol.

Spinal Motion Restriction (SMR)

The goal is to minimize harmful movement of a potentially injured spine, not to achieve rigid immobilization at all costs. Current evidence and updated protocols (including position statements from NAEMSP and the American College of Surgeons) support selective SMR: apply spinal precautions to patients with a realistic mechanism for spinal injury plus clinical indicators (midline neck or back pain, neurological deficits, altered mental status, distracting injury, or intoxication).

Technique: Size and apply a cervical collar before any move. Three-person log-roll onto a long spine board or use a scoop stretcher. Secure torso straps before head straps — this prevents the board from levering the head if it shifts. Use a head immobilizer (foam blocks and tape), not sandbags, which can shift. Verbalize your indications, reassess distal neurological function after securing, and document everything.

Helmet removal: Sports helmets with a well-fitting face mask — remove the face mask and leave the helmet if it fits well and the airway is accessible. Remove a motorcycle helmet if you cannot access the airway or maintain alignment.

Burns

Depth classification:

• Superficial (first-degree): Epidermis only. Red, dry, painful. Not counted in BSA calculations.
• Partial-thickness (second-degree): Into the dermis. Blistered, moist, extremely painful.
• Full-thickness (third-degree): Through all skin layers. Leathery, waxy, or charred; often painless at the burn center due to nerve destruction.

Rule of Nines estimates total body surface area (TBSA) burned in adults: Head and neck = 9%, each arm = 9%, chest = 9%, abdomen = 9%, upper back = 9%, lower back = 9%, each thigh = 9%, each lower leg = 9%, genitalia = 1%. Total = 100%. For children, the head is proportionally larger; use the Lund-Browder chart or a length-based tape when available.

Airway is the first priority for facial burns, singed nasal hair, hoarse voice, carbonaceous sputum, or a history of being in an enclosed space fire — signs of inhalation injury. These patients can deteriorate rapidly; consider ALS intercept and early notification to the receiving facility.

Management: Cool burns with room-temperature water for up to 10 minutes (no ice, no butter, no home remedies). Cover with dry, non-adherent dressings. Keep the patient warm — large burns cause rapid heat loss. Do not break blisters. Chemical burns require continuous flushing; brush dry powder off before flushing. Electrical burns may have entry and exit wounds; assume cardiac monitoring is needed.

Head and Brain Injury

Distinguish scalp lacerations (which bleed heavily but are rarely life-threatening) from traumatic brain injury (TBI). Signs of increasing intracranial pressure: altered mental status, unequal or unreactive pupils, Cushing's triad (hypertension, bradycardia, irregular respirations — a late and ominous sign), posturing, or deteriorating GCS. Maintain airway, oxygenate to SpO₂ ≥ 94%, and transport rapidly. Avoid hypotension — it worsens outcome. Apply SMR for head trauma with any neurological finding or significant mechanism.

Chest Trauma

Key injuries to recognize:

• Flail chest: Paradoxical movement of a chest segment. Treat with positive-pressure ventilation if breathing is inadequate.
• Open chest wound (sucking chest wound): Apply a vented (three-sided) chest seal; if patient deteriorates after sealing, consider tension pneumothorax and burp or remove the seal per protocol.
• Tension pneumothorax: Absent breath sounds unilaterally, tracheal deviation (late), hypotension, JVD — rapid deterioration. ALS needle decompression required.
• Cardiac tamponade: Beck's triad — hypotension, JVD, muffled heart sounds. Requires ALS and rapid transport.

Safety Points for This Lab

• Traction splint cranks and ratchets can apply significant force — increase traction gradually and watch the patient.
• When practicing SMR on student volunteers, the designated in-line manual stabilization holder calls all moves; no one moves until that person says so.
• Moulage makeup and theatrical burns can cause contact dermatitis; students with skin sensitivities should notify the instructor before application.
• Dispose of single-use gloves and wound-simulation materials in appropriate waste containers.