4.3 Special Trauma Populations & Environment
Key Takeaways
- Pediatric trauma patients have larger relative head size, greater physiologic reserve that masks shock until sudden collapse, and rapid heat loss.
- Geriatric patients on anticoagulants or beta-blockers can have severe internal bleeding with a 'normal' heart rate, so a low triage threshold is essential.
- A pregnant trauma patient in the third trimester is transported tilted left (or with manual uterine displacement) to relieve aortocaval compression; resuscitating the mother resuscitates the fetus.
- Severe environmental hypothermia management is gentle handling, prevention of further heat loss, and the principle that the patient is 'not dead until warm and dead.'
- Selective spinal motion restriction uses validated criteria; a properly sized cervical collar plus securing the whole body to a firm device limits motion without mandatory long-board transport for every patient.
Special Trauma Populations
Age and physiology change how trauma presents and how the AEMT must respond. The exam tests whether you adjust assessment and triage for these patients.
Pediatric Trauma
- Anatomy: A proportionally larger head increases head-injury risk; a more flexible skeleton can transmit force to organs without rib fractures; a large surface-area-to-mass ratio causes rapid hypothermia.
- Physiology: Children compensate well and may keep a near-normal blood pressure until they crash suddenly. Tachycardia and poor perfusion (cool extremities, weak pulses, delayed capillary refill, altered behavior) are the early shock signs — do not wait for hypotension.
- Use length-based tools for sizing and weight estimation, keep the child warm, and minimize scene time.
Geriatric Trauma
- Lower-energy mechanisms (ground-level falls) can cause major injury due to fragile bone and brain atrophy (rising risk of subdural bleeding).
- Medications mask and worsen injury: beta-blockers blunt the tachycardic response so a 'normal' heart rate can hide shock; anticoagulants and antiplatelet drugs cause severe occult bleeding from minor trauma.
- Maintain a low threshold for trauma-center transport even when vitals look reassuring.
Trauma in Pregnancy
The priority is the mother: the best fetal resuscitation is effective maternal resuscitation.
- After about 20 weeks the gravid uterus can compress the inferior vena cava and aorta when supine (supine hypotensive / aortocaval compression syndrome).
- Transport the patient tilted 15-30 degrees to the left, or manually displace the uterus to the left.
- Maternal blood volume is expanded, so a pregnant patient can lose substantial blood before showing classic shock signs while the fetus is already compromised.
- Provide high-flow oxygen, treat for shock, and transport to an appropriate facility. Watch for trauma-related complications such as placental abruption (abdominal pain, vaginal bleeding, rigid uterus) and preterm labor.
Multisystem Trauma
Multisystem (polytrauma) means injuries to more than one body system or region, where the combined physiologic burden is greater than any single injury. Approach:
- Treat the greatest life threat first using the primary assessment; do not anchor on the most visually dramatic wound.
- These patients are at high risk for the lethal triad: hypothermia, acidosis, and coagulopathy.
- Multisystem trauma almost always meets major-trauma triage criteria — minimize on-scene time and transport to the highest-level trauma center with early notification.
Environmental Emergencies
Heat Illness
| Condition | Key Signs | AEMT Action |
|---|---|---|
| Heat cramps | Painful muscle spasms, sweating | Rest, cool environment, oral fluids if alert |
| Heat exhaustion | Heavy sweating, weakness, nausea, normal/slightly altered mentation | Cool, supine, fluids, monitor |
| Heat stroke | Altered mental status, very high temperature, often hot skin | Rapid aggressive cooling, airway, transport now |
Heat stroke is a true emergency — altered mentation with hyperthermia is the red flag; begin rapid cooling immediately and transport.
Cold Injury
- Hypothermia: Handle the patient gently (rough handling can precipitate cardiac arrhythmias), remove wet clothing, insulate, and prevent further heat loss. In severe hypothermia, pulse checks are prolonged; remember 'not dead until warm and dead.' Continue resuscitation and rewarming efforts.
- Frostbite: Do not rub the area and do not rewarm if there is any chance of refreezing; protect the part and transport.
Drowning
Drowning is primarily a hypoxic event. Prioritize airway and ventilation/oxygenation — rescue breaths and effective oxygenation are central. Suspect spinal injury only with a consistent mechanism (e.g., diving). Anticipate vomiting, keep the patient warm, and transport even if the patient appears to recover, because delayed respiratory deterioration can occur.
Splinting and Spinal Motion Restriction
Splinting Principles
- Assess pulses, motor, sensory (PMS) distal to the injury before and after splinting.
- Immobilize the joint above and below a fractured bone; pad rigid splints and splint in the position found unless there is no distal pulse and protocol allows one gentle realignment attempt.
- A traction splint applies to an isolated mid-shaft femur fracture; do not use it with a suspected pelvic, knee, hip, or lower-leg injury.
Spinal Motion Restriction (SMR)
Current EMS practice favors selective SMR over routine long-board immobilization for all trauma patients. Apply full SMR when validated criteria are present, such as:
- Altered mental status, intoxication, or inability to communicate reliably
- Midline spinal tenderness or focal neurologic deficit
- A distracting injury or a high-risk mechanism
Provide a correctly sized rigid cervical collar and secure the entire body to a firm transport surface (stretcher, vacuum mattress, or board per protocol) to limit movement; a collar alone does not restrict the whole spine. A penetrating injury to the head or neck without neurologic deficit generally does not require spinal immobilization, and delaying transport to apply it can be harmful.
A 3-year-old struck by a vehicle has a heart rate of 168, cool mottled extremities, weak distal pulses, and a systolic blood pressure that is still within the normal range for age. How should the AEMT interpret this?
A 78-year-old on a beta-blocker and an anticoagulant fell from standing height and struck her head. She is mildly confused with a heart rate of 76 and a blood pressure of 128/76. What is the most appropriate AEMT action?
A 32-week-pregnant patient involved in a motor-vehicle collision is hypotensive when lying flat on the stretcher. What positioning intervention should the AEMT use during transport?
An AEMT is treating a patient pulled from cold water who is severely hypothermic with no obvious pulse after a careful, prolonged check. Which principle should guide care?