National Registry Paramedic Exam: Trauma 1 - Physics of Trauma

Objectives
- Describe anatomy, physiology, and physics associated with traumatic injuries.
- Assess and treat hemorrhage; soft-tissue injuries; and thermal, chemical, electrical, and radiation burns.
- Assess and treat musculoskeletal injuries, including fractures, dislocations, sprains, and strains.
- Differentiate, assess, and treat various head injuries, neurological injuries, and spinal cord injuries.
- Differentiate, assess, and treat thoracic injuries to the heart, lungs, and great vessels.

Trauma involves injury to the person by any outside force. Injuries the body can sustain and overcome are widely varied and often depend on how long it takes a person to get definitive care at the hospital. EMS plays a very important role in this aspect of trauma care. As the paramedic, it is your responsibility to rapidly triage, treat, and transport a patient to a facility capable of continuing treatment. In many cases, surgical procedures are required to alleviate injuries, repair internal lacerations to organs, or set broken bones. Getting the patient to such a facility capable of emergency operations is the overarching goal of paramedicine for the trauma patient.

Throughout this guide, you will come across references to the index of suspicion. The index of suspicion is that nagging feeling that something more than can be seen or otherwise experienced is wrong with the patient. It also is anticipating that something more is wrong and potentially life threatening. For example, keep a high index of suspicion that your patient has a developing pneumothorax when you find crepitus and a rib fracture, despite not having notably diminished lung sounds of JVD. It may turn out not to be true, but a high index of suspicion will lead the paramedic to treat aggressively, possibly leading to saving time and ultimately a life.

1. Physics of Trauma
Trauma results when the amount of energy that is transmitted into the human body exceeds the body’s ability to cushion itself or dissipate the transmitted energy. Think about it this way: If a person were to punch another person in the shoulder, the victim would likely not even sustain a bruise from it. In this case, the body of the person who was punched successfully dissipated the energy the punch delivered to it, and trauma from the event is minimized. If this same person would instead have been hit with a baseball bat in the same shoulder swung by a professional major league baseball player, the victim would likely come away with a few broken bones. In this case, the body did not successfully dissipate the energy, and a traumatic event occurred. Warning: Do not attempt this thought experiment in real life!

Energy
Various kinds of energy can cause injury to patients.

Mechanical energy is the energy of an object, generally an object in motion. Mechanical energy in physics has 2 distinct components: kinetic energy and potential energy. Potential energy is energy that an object possesses based on the virtue of its position and, therefore, its potential to release energy. For example, a ball sitting on the ledge of a tall building has potential energy, but no energy that will hurt anyone anytime soon, until it falls off the ledge. Once it does fall off the edge, it now possesses kinetic energy (KE), which is the energy of motion. Cars in motion, things falling, or airborne bullets all possess KE. If they impact a person, the person may sustain injuries.
Chemical energy is released whenever existing chemical bonds are broken. When these bonds are broken, they release heat. If the heat is high enough, it can produce burns. Chemical energy is released in dramatic fashion whenever something burns or explodes, but it also can be more insidious, such as when an acid gets on skin.
Electrical energy is a special form of chemical energy and can be found in electrical lines or lightning strikes.
Pressure, although not technically an energy, is a force. If this force is applied in high enough quantity, it can cause injury. Think back to the information on changes in pressure during diving.

Kinetics and Force
The mechanism of injury is something that every paramedic should evaluate in a trauma patient. This helps determine how much energy was transferred to the patient and predict what injuries the patient may have sustained. Evaluating the mechanism involved may not always be obvious. The quantity and direction of the force and energy play an important role as well as the duration of time the force is exerted.
The KE an object possesses is exclusively dependent on 2 factors: mass and velocity. The mass of an object is essentially its weight, and velocity is the distance the object travels per unit of time. Velocity, by definition, also specifies a direction. According to the equation, the velocity of the object impacts the overall KE significantly more than the mass of the same object. This means that a light object traveling at a high rate of speed could potentially carry more KE than a large object moving slowly.

The KE of a falling object, on the other hand, is entirely dependent on the height from which the fall started and the mass of the object falling. During the fall, the potential energy an object possesses before it begins to fall is completely converted to KE just before it impacts the earth. With this in mind, the potential energy of the object is based on the height of the object, the mass of the object, and the acceleration due to gravity. The acceleration due to gravity is always 9.8 m/s2 within a reasonable distance from sea level on Earth. Unlike in the previous equation, the 2 values that can change in this scenario are height (h) and mass (m). Neither impacts the overall energy of the falling object more than the other.

The variable in this equation that will affect injuries suffered by a patient most, however, is height. For this reason, paramedics focus on the height of the fall far more critically than the mass of the patient falling.
Aside from these finite values that have a measurable effect on the patient, other factors include the position of the patient during the impact, the object the patient impacted, the duration of time the force or the energy is applied, and the overall resistance of the body area impacted. These factors are not completely independent of each other.
The position of the patient at the time of impact can have wide-ranging effects on the degree of trauma sustained. For example, a person who fell out of a tree stand and landed on his or her buttocks or feet will have a completely different prognosis and set of injures than the person who landed head first. The child who is hit by a car while attempting to run out of its way will sustain different injuries than the child who turns and faces the car. Finally, the person who is sitting sideways in the passenger seat of a car, perhaps talking to passengers in the backseat will have different injuries during a head-on collision than the person who is seated properly. Although it is not necessarily possible to say which of the patients in these pairs of examples would fare worse in most cases, it is understandable that they would have different injuries.
The object on which the falling patient lands or against which the patient in a vehicle impacts plays a significant role in the patient’s injuries. This often has to do with extending the period of time the force is applied. To put this into perspective, think of the stunt person who falls from a building. When landing, he or she does not get injured because the person impacts a large, air-filled pillow that slowly brings him or her to a stop. The stunt person does not collide with the pavement, which would instantly bring the person to a stop and result in untold injuries.
Consider the less dramatic fall down the stairs: a person who falls down an iron fire escape likely will suffer more injuries than a person who falls down the same number of thick carpeted steps. In the case of the stunt person’s pillow or the patient who fell down the carpeted steps, what each person landed on spread out the area of the impact and lengthened the time of the impact, lessening the injuries. It also is the concept behind vehicular airbags, which extend the time over which a person decelerates.
Finally, the impact resistance of body parts has to do with the likelihood that injuries will be sustained as a result of some impact. The younger person playing impact sports is less likely to sustain injury than an elderly adult because of a flexible rib cage, for example. Certain body parts are also more resilient to damage as well. The solid organs of the body are much less compressible and are therefore more likely to rupture when compressed. Air-filled organs, on the other hand, can dissipate the impact more successfully, similar to the stunt person’s pillow.
Scientific laws rule over what happens during any collision. The law of conservation of energy states that energy can neither be created nor destroyed, but it can be converted from one form to another. This is illustrated in a car crash when a car collides with an immovable object: the car bends, windows break, and the sound of the impact all release the KE the car possessed just before the impact. The energy also is converted into heat because of the friction of the car against the object.

Newton’s 1st law of motion states that an object at rest will remain at rest until acted on by an outside force; an object in motion will remain in motion and traveling in a straight line unless acted on by an outside force. This also is seen in motor vehicle crashes. After the car comes to a complete stop, the person inside will continue moving forward at the same velocity as immediately before the impact, until the seat belt tenses or the person collides with the steering wheel or airbag.
Newton’s 2nd law of motion states that the force an object will exert on another object is equal to the product of the mass of the object and the acceleration of that object. This is a little bit more difficult to experience. Acceleration is the change in velocity over a specific period of time. Let’s consider a car that collides with the immovable object and say that the 1,000 kg car is moving at 20 m/s (meters per second or approximately 45 mph). An accident of this type brings the car completely to rest in about 0.5 second. This makes the acceleration (or in this case, deceleration) of the car during the accident 40 m/s (20/0.5 = 40). Multiplying these 2 values together, the force exerted on the car—and by extension the occupants—is 40,000 N. (The unit of force is the Newton.) In the equation below, F represents the force, m is the mass of the object in question, and a is the acceleration of the object. Note also that a represents velocity (v) divided by time (t).

Blunt Trauma
Injuries resulting from compression or nonpenetrating forces are called blunt trauma. Motor vehicle accidents and falls account for the majority of causes of blunt trauma and also are known as deceleration injuries. Earlier, it was noted that at the time of a vehicle crash, although the car stops, the occupant continues to move at the same speed as prior to the collision until the person encounters the steering wheel or some other object in the car. As the patient makes contact with this object, the person’s exterior begins to slow down, but the interior organs continue to travel at the same speed. As the person impacts the body wall, he or she begins to compress, resulting in injury, especially to the solid organs. Based on the point of impact on the patient’s body and the factors noted prior, injury patterns can be predicted.
Some common injury patterns in motor vehicle crashes are as follows:
Front-End Impacts. This impact occurs when the deceleration force is directly opposite the initial direction of travel. The occupant will slow down at the same rate as the rest of the car and will sustain injuries of the anterior part of the body. Unrestrained occupants will travel either the down-and-under route or the up-and-over route. The down-and-under route will result in lower body injuries predominantly as the knees impact the underside of the dashboard, whereas the up-and-over route could result in the patient’s head colliding with the roof or windshield, and the chest and abdomen colliding with the steering wheel. Ejection is possible if the velocity of the patient is too great for the windshield to stop it.
Lateral or T-Bone Impacts. These collisions place the brunt of the force on the passenger compartment door panel at about the midpoint of the car. The occupants on the same side of the impact will suffer the greatest injuries as their seating area becomes compressed and they are essentially squeezed between the colliding object and the center console (if present) or by the other occupant if the overall width of the car changes that drastically. In this kind of collision, the head will snap violently downward and toward the direction of the impact resulting in whiplash injuries and possibly brain injuries. The chest and hips are directly impacted, and fractures or a pneumothorax are possible, if not likely.
Rollovers. If the lateral impact is below the center of gravity of the vehicle, the impact may cause the car to roll over. This has the potential to cause myriad injuries, especially if the patient is unrestrained. Unrestrained patients in a rollover accident could be ejected from the vehicle or end up in another location within the vehicle from where they started. Maintain a high index of suspicion with these unrestrained patients because wherever they come to rest, they did not arrive there in a friendly way.
Rear-End Impacts. The collision often is from a car traveling faster and colliding with slower moving traffic. In an isolated impact, this is usually the most survivable crash with the fewest major injuries. Whiplash injuries are most common as the head moves backward relative to the body during the impact but then snaps forward as the car slows down again. This may be the worst of the issues. However, if during the collision the car is pushed into another car or into oncoming or cross traffic, injuries are no longer predictable and could very well be life threatening.
Rotational or Quarter Panel Impacts. Often occurring at an intersection, 1 vehicle impacts another at the area of the tire, rather than the middle of the vehicle as in a T-bone. Because the impact is away from the center of mass of the vehicle, it will rotate to dissipate the energy from the impact. Injuries are widely varied and depend largely on the point of impact relative to the passenger and whether the passenger was restrained or not.

Tip: On any crash scene, take a moment away from patient care and evaluate the damage to the vehicle. Note deformity in inches from where the exterior of the car was before the impact to where it is now, keeping in mind that most modern cars are designed to crumple around the passenger compartment, transmitting energy around the passenger compartment rather than through it. Note intrusion into the passenger compartment; anything more than a foot is considered a significant mechanism. Note if any airbags deployed and if the seatbelt was used. Note whether the surrounding windows are intact. Finally, note any damage to the interior of the passenger compartment, dashboard, steering wheel, or center console. All of this is part of a comprehensive patient assessment and should be relayed to the receiving facility and documented in the patient care report after the call.

Restraints
Seatbelts and airbags have saved countless motorists’ lives because they prevent ejections, minimize passengers impacting the inside of the vehicle, and expand the time of impact of the patient and spread the forces of the impact over a greater area. Seatbelts can cause injuries of the chest, including bruising and possibly fractured ribs or clavicle, but these injuries likely pale in comparison from what could have happened without the seatbelt. The airbag relies on rapidly expanding hot gases to inflate faster than the forward movement of the patient. Consequently, minor burns from the powder and gases of the airbag often are reported. Abrasions to the chest and face also are complications of airbag deployment. Children in the front seat can be killed by the airbag expansion.

Motorcycle Crashes
Motorcycle crashes can happen in the same way as with cars, except that the riders do not have any meaningful protection. Ejection from the motorcycle is highly likely, and injuries are not predictable. There are several types of motorcycle impacts.
Head-on Impact. This stops the motorcycle’s forward movement. In this type of collision, the rider is usually ejected up and over the handle bars. This motion could result in 1 or both of the rider’s legs becoming caught on the pegs while simultaneously contacting the handlebars. This type of collision often results in bilateral femur fractures or possibly tibia or fibula fractures.
Angular Impact. This is close to a sideswipe impact but often results in one of the rider’s legs becoming temporarily trapped between the bike and the car. This can result in extensive orthopedic damage to that leg.
Laying the Bike Down. This is an option the driver may take to avoid a worse collision. This allows the rider to deliberately separate from the bike. If the rider has worn proper protective equipment, including lower body leather or Kevlar, this should minimize long-term injuries and even may eliminate road rash. If the biker is not able to separate from the bike, however, the results could be devastating.
Motorcycle helmets are no longer required in many states, although more safety-oriented riders still opt to use them. If a helmet was worn at the time of the accident, the paramedic should evaluate it for abrasions or cracks and take it along to the hospital with the person who was wearing it. Any damage found on the helmet should be assumed to have been transmitted to the rider’s head and neck until proven otherwise at the hospital. If the rider is still wearing it when EMS arrives, it should be removed carefully to allow for better access to the airway and proper in-line immobilization.

Pedestrian Accidents
In a pedestrian accident, there are 3 impacts, each of which can cause injuries. First, a car or truck collides with the individual, leading to injuries of the lower extremities, often ripping feet out of tightly laced shoes. Second, the torso, upper extremities, and head collide with the hood, causing injuries to those areas. Finally, the force of the impact provides sudden acceleration to the pedestrian and throws the patient. The third impact is when the person finally hits the ground and comes to rest. Adult pedestrians are more likely to be hit on their side as they walk or run to get out of the way, whereas children tend to turn and face the oncoming vehicle, resulting in more facial trauma caused not only by facing the vehicle but also their shorter stature.

Falls
As mentioned earlier, the severity of injury is primarily a result of the height from which the patient has fallen. Remember also that the acceleration due to gravity is 9.8 m/s2, which means a person falling for just 2 seconds will hit the ground at nearly 45 mph! The duration of the fall can be impacted only by the height from which the person falls. Falls from heights of 3 times the height of the person are generally considered a significant mechanism of injury, and falls of about 50 feet (5 stories) or more are not likely survivable.
Extending the amount of time for deceleration increases the likelihood that a person will survive the fall. This can be accomplished with a large inflatable pillow for the stunt person; for shorter falls, it can simply include falling onto softer ground rather than cement. Consequently, what a person lands on plays a great role in severity of injury. In addition, it is worth noting that water at high speeds or falls from great height offer little in the way of a softer landing place and can be as hard on the body as concrete in a fall. Finally, take a moment to evaluate what the patient may have collided with on the way down. A straight fall without hitting any obstructions is generally less significant than one that struck many obstructions on the way down because each obstruction will be a narrow, rather than broad, point of impact on the body. It also may cause the body to rotate, further complicating the injuries sustained.
The physical condition of the patient could impact the severity of injuries that a patient sustains. Remember that the elderly person with brittle bones will become more easily injured than a younger child under the same conditions. Furthermore, the medications the patient takes and his or her comorbid conditions, such as cardiac or lung disease or diabetes, may significantly impact the recovery time from any injury—regardless of severity.
Finally, the part of the body that sustains the initial impact during a fall also can affect the severity of the injury. Children frequently fall head first simply because of the disproportionate amount of mass concentrated in their upper bodies. Landing with legs outstretched and knees locked can transmit the impact all the way up into the pelvis and spine, which can lead to acetabular fractures and compression fractures of the vertebrae.

Blast Injuries
During an explosion, 5 types of injury can occur: primary, secondary, tertiary, quaternary, and quinary. 

Primary blast injuries are caused entirely by the pressure wave generated by the blast itself. Secondary blast injuries result from shrapnel, rocks, or anything in the vicinity of the blast becoming airborne and striking the patient. The pieces of material can travel in excess of 2,000 mph and can impale the victim. Tertiary blast injuries are caused by a person being hurled into the air and into another object, such as a wall, or knocked over onto the ground. These occur as a result of the pressure wave. Quaternary blast injuries are caused by other events surrounding the blast, such as burns from hot gases or flames or respiratory condition resulting from the inhalation of toxins. Finally, quinary blast injuries are found in the so-called dirty bomb. This releases contaminants, such as fertilizer, VX gas, deadly bacteria, or radioactive materials, into the surrounding area during the explosion.


Figure: Primary, Secondary, and Tertiary Blast Injuries

Treatment of blast injuries requires a high index of suspicion and means being prepared to treat life-threatening injuries. The injuries can be as wide ranging as ruptured tympanic membranes, lungs, and other gas-filled structures as a result of the pressure wave and other blunt trauma to burns, lacerations, and fractures. It is possible to spend extensive amounts of time in projecting possible injuries resulting from any one of the above levels of blast injuries, but it is best to conduct a thorough head-to-toe assessment, aggressively treating any derangements of the ABCs found.

Penetrating Trauma
Penetrating trauma includes any type of puncture to the skin at least, but it usually involves underlying structures. Penetrating trauma is classified as low, medium, and high velocity. Low-velocity penetrating trauma encompasses stab wounds and penetrations sustained from falls or countless other ways of puncturing the skin. The severity of a stab wound is determined by the following factors:

- Damage to structures underlying the area of the skin penetrated.
- Is the knife waved around inside the body or just plunged into it? Moving it around can have the effect of broadening out the area of the stab wound.
- What is the depth of the penetration?
- Was the penetrating object removed and reinserted? If the knife or other object is plunged in and allowed to remain, the knife or penetrating object’s presence may be enough to tamponade any bleeding, making the injury less significant than it may otherwise have been.

Medium- and high-velocity penetrating wounds are generally from a firearm or other projectile. Firearms, listed here in decreasing order from high velocity to medium velocity, include rifles, shotguns, and handguns. Rifles produce the highest muzzle velocity of weapons and fire a single, comparatively large bullet that follows a straight path.
The shotgun is still considered high velocity; however, the initial velocity is slower than that of a rifle and higher than that of a handgun. The shotgun, in contrast rifles and handguns, fires a shell that is loaded with smaller pellets. The pellets vary in size but tend to scatter upon ejection from the muzzle. At distances less than about 30 feet, the shotgun blast can be devastating, the unevenly shaped pellets cause widespread injury, tearing and shredding through the tissue, carrying clothing, hair, and other material into the wounds they create.
The handgun fires a single bullet at a time with reasonable accuracy—more than the shotgun but less than the rifle—because of both the shorter barrel and sight radius. Bullet diameters for the handgun can vary anywhere from less than a quarter inch to nearly half an inch. The larger the bullet diameter, the more likely it is to travel in a straight line and the more difficult it is to be deflected off a straight pattern. Smaller bullets can ricochet off organs of differing densities or bone, whereas larger ones are more likely to tumble in a straight line. Tumbling increases the amount of damage done along the travel pathway. Furthermore, the cavitation wave the bullet produces, similar to the wake a fast-moving boat leaves in water but in all directions, can cause even more damage and bruising to surrounding tissues.
Much discussion often is given to entrance and exit wounds and how to distinguish each type. As a paramedic, the wounds should not be labeled “entrance” or “exit”; rather, an objective description of each should be given clearly in the patient care report. Although it is true that entrance wounds often are small, roughly approximating the size of the bullet that entered, and exit wounds often are large and appear as if an explosion happened just below the skin caused by the cavitation wave, this is not an absolute rule. Instead, document the appearance and location of any wounds found.

Trauma Criteria, General Assessment, and General Treatment
Genuine multisystem trauma calls can be extremely stressful for the paramedic. A whole lot went wrong all at once, resulting in difficult scenes and multiple patients with widely varying complaints. The scenes more often than not are a chaotic hub of activity, sometimes involving multiple agencies and levels of training, occasionally with conflicting priorities. The extrication of the patient may require hours of time and specialized equipment, and the coordination of efforts to free a patient is complicated. Finally, patient injuries are sometimes occult and need to be found through diligence of a systematic assessment.
The assessment of the multisystem trauma patient should follow a systematic and consistent pattern to minimize the possibility of missing something. Multisystem trauma refers to a traumatic event that involves more than one of the body’s systems. For example, a patient who fell and sustained a pneumothorax and fractured ribs has sustained damage to the respiratory and musculoskeletal systems. This is always more significant than an isolated injury, such as an eye injury or a fractured ankle. The body can more readily deal with the isolated injury, rather than multiple and widespread problems all at once.

The assessment should begin by assessing the airway, breathing, circulation, disability, and exposure.

- Airway. Focus on determining the patency of the airway during respirations and assess for the patient’s ability to maintain a patent airway going forward. If the patient is not likely to be able to maintain his or her airway, consider intubation or the placement of an alternative airway.
- Breathing. Focus on the quality and effectiveness of breathing; initially, a rate is not required. If breathing has adequate tidal volume and appropriate minute volume, provide supplemental O2. If breathing is deemed inadequate or ineffective, provide positive pressure ventilations with a BVM and consider intubation as soon as feasible if the patient is not combative, clenched, or seizing.
- Circulation. Assess in 3 distinct ways: (1) observe for any massive bleeding, (2) assess for skin color and temperature, and (3) assess for the presence and quality of a pulse. Here again, pulse rate is not specifically needed—fast, slow, or normal is sufficient during this rapid assessment. At this point in the assessment, control any major external bleeding and begin to plan for prevention of and treatment for shock.
- Disability. Once the ABCs have been addressed, assess the neurological status of the patient. This is done generally with AVPU and then more specifically by obtaining a GCS reading. Assess for loss of consciousness and overall level of consciousness.
- Exposure. In multisystem trauma, it is not possible to fully assess the patient who is still clothed. The patient should be stripped completely naked, except, under most circumstances, his or her underwear. It is rarely necessary to assess genitalia or breasts in the trauma patient. If it should be necessary, expose the area for assessment and treatment and then cover the area back up as soon as treatment allows. Maintenance of dignity is important unless it interferes with treating a potentially life-threatening injury. Whenever possible, perform this step in the confines of the ambulance, not in the view of the general public.

Vital signs should always be obtained as soon as possible and every 5 minutes or so throughout contact. The patient who has sustained multisystem trauma should be placed on a cardiac monitor, and intravenous access should be obtained with fluids running to maintain an SBP of >100. Minor bleeding should be bandaged at this point, and extremities suspected of having a fracture or dislocation can be splinted. It is worth keeping in mind, however, in massive trauma, that the paramedic may never get to any meaningful assessment or treatment beyond managing ABCDE.

Trauma Criteria
The paramedic will need to decide if the patient needs to go to an accredited trauma facility or if he or she can be treated at a regional or community hospital. In many cases, when multisystem trauma is present, a trauma facility is recommended. The American College of Surgeons has made recommendations on which patients need a trauma center. If the patient meets any 1 of the following criteria, he or she should be transported to a trauma center via the most efficient means possible. 

Physiological Criteria
- GCS ≤13 at any point during patient contact
- SPB ≤90 at any point during patient contact (<110 in elderly patient >65 years)
- Respiratory rate outside the range of 10–30 per minute or on ventilatory support

Anatomic Criteria
- Any penetrating trauma to head, neck, torso, or proximal extremities
- Chest trauma, including fractures
- 2 or more proximal long bone fractures
- Crush injury to any extremity
- Degloving injury
- Pulseless extremity
- Amputation proximal to the wrist or ankle
- Pelvic instability
- Open or depressed skull fracture
- Paralysis
 

Mechanism of Injury Criteria
- Fall >3x the body height (children) or 20 ft (adult)
- Car versus pedestrian or bicyclist where the person is thrown, run over, or struck at speeds >20 mph
- Motorcycle crash at speeds >20 mph

- Car crash involving any of the following: 
- Intrusion into passenger compartment >12 in.
- Ejection from the vehicle
- Death of another occupant in the same vehicle

- Special Considerations 
- Patient age >55 years
- Patient is pregnant
- Burns of any kind with other trauma present
- Patient takes anticoagulants or has a bleeding disorder
- EMS provider judgment

Mode of Transport
If the patient meets any of the aforementioned criteria, he or she must be taken to a trauma center. The paramedic must make the decision on how to get the patient to the hospital. There are 2 options: ground or air. The paramedic should consider the following criteria before electing to fly the patient:

- Can the trauma center be reached within about 20 minutes by ground? If the transport time is less than about 20 minutes, factoring in weather and traffic, then the patient should be transported by ground. Outside that range, aeromedical flight should be considered.
- Is there difficulty in accessing the patient? This can be caused by rough or remote terrain, such as forest trails or extensive off-road travel needed, or entrapment and the need for complicated, time-consuming extrication. If the rescue company predicts that the patient will take long enough to extricate and that a helicopter could have landed by the time the patient is freed from the vehicle or extricated from the rough terrain, and injuries meet the previous criteria, then flight is recommended.
- Does the patient require medical care beyond that of the resources available on the scene? Flight nurses and paramedics generally have a broader scope of practice and can provide more extensive care than ground crews. This can include the administration of paralytics to aid in intubating a combative patient or the patient whose jaw is clenched as a result of a head injury. If this level of care is needed and not available on the ground transport unit, aeromedical transport is preferred.
- Is this a multiple casualty incident (MCI)? If multiple patients are at an event, it is advisable to send the most critically injured by air so that the ground resources are not stripped from a certain area. With that in mind, it is not recommended to send any of the patients from an MCI by air if the patients do not meet criteria. Aeromedical transport is exorbitantly expensive and rarely covered by any insurance.