05 Trauma and Injury Management
A practical progression through EMT trauma care, from scene safety and primary assessment to hemorrhage control, injury-specific management, shock recognition, and rapid transport decisions.
Start with Scene Safety and Mechanism
Trauma care begins before patient contact. The EMT must protect personal safety, identify hazards, recognize the mechanism of injury, request resources early, and decide whether rapid transport is needed.
Scene size-up priorities
Use standard precautions and assess for traffic, fire, weapons, electricity, hazardous materials, unstable structures, and additional victims.
Determine the mechanism of injury by considering speed, direction, distance of a fall, vehicle intrusion, restraint use, ejection, death in the same passenger compartment, blast exposure, and penetrating objects.
Determine the number of patients and whether triage is required.
Request additional personnel, extrication, law enforcement, advanced life support, or a trauma-center destination when indicated.
Consider when the mechanism, findings, or patient condition creates a credible risk of spinal injury.
Avoid unnecessary movement, but do not delay essential care when the scene is dangerous or the patient has an immediate threat to life.
Takeaway: A safe, organized scene size-up guides the entire trauma response and helps the EMT match resources and transport urgency to the patient’s risk.
Identify Life Threats First
The primary assessment identifies and treats problems that can kill the patient within minutes. Use a rapid, organized sequence and treat each life threat as soon as it is found.
Primary assessment sequence
General impression and mental status: Note appearance, position, responsiveness, work of breathing, and skin signs.
Airway: Look for obstruction from blood, vomit, loose teeth, facial trauma, or swelling. Open the airway while protecting the cervical spine when indicated.
Breathing: Assess rate, depth, effort, chest expansion, breath sounds, oxygenation, and signs of immediately life-threatening chest trauma.
Circulation: Check a central pulse in an unresponsive or critically ill patient, evaluate the skin, identify severe bleeding, and look for shock.
Disability: Assess mental status, pupils, motor function, sensation, and glucose when clinically indicated.
Exposure and environmental control: Expose enough of the patient to identify injuries, then prevent heat loss.
Do not delay transport for a lengthy examination when there is uncontrolled hemorrhage, airway compromise, inadequate breathing, shock, altered mental status, or another indication for immediate transport.
Secondary assessment
After immediate threats are managed, obtain a focused history and perform a rapid head-to-toe examination. Look for findings, pain characteristics, loss of consciousness, vomiting, seizures, amnesia, medications, allergies, relevant medical history, anticoagulant use, vital-sign trends, and distal pulse-motor-sensation changes.
Reassess frequently because occult bleeding, airway swelling, chest injury, brain injury, and shock can worsen after an initially mild presentation.
Takeaway: The primary assessment is for immediate threats; the secondary assessment adds detail only after those threats are being managed.
Control Hemorrhage and Protect Soft Tissue
Severe external bleeding requires immediate, continuous control. Use a progression that matches the wound and the severity of hemorrhage.
Controlling life-threatening bleeding
Apply firm, continuous direct pressure with gloved hands or a dressing.
If bleeding continues from a deep wound, pack it with hemostatic gauze, plain gauze, or clean cloth when appropriate, then maintain pressure.
For severe extremity bleeding that remains uncontrolled, apply a proximal to the wound. Tighten it until bleeding stops and document the application time. Do not loosen or remove it in the field unless directed by medical control.
Treat for shock, keep the patient warm, and transport promptly.
Do not repeatedly lift a dressing to inspect the wound because this can disrupt clot formation. Elevation alone is not a substitute for effective direct pressure or a when those measures are indicated.
Soft-tissue wounds
An abrasion is a superficial scraping of the skin.
A laceration is an irregular cut that may involve tendons, nerves, or deep structures.
An incision is a clean-edged cut that may still be serious.
A puncture has a small surface opening but may cause deep injury.
An avulsion involves tissue partially or completely torn away.
An amputation requires immediate hemorrhage control and shock treatment.
An impaled object should be stabilized in place and not removed unless it interferes with airway management or chest compressions.
For avulsed or amputated tissue, cover it with a moist sterile dressing, place it inside a sealed bag, and keep the bag near rather than directly on ice. Bites and contaminated wounds also require attention to infection, tetanus, rabies when relevant, and deeper structural injury.
Takeaway: Control bleeding first, preserve tissue when possible, and never let wound appearance alone determine the urgency of care.
Manage Burns and Airway Risk
Burn management combines stopping the burning process, identifying high-risk features, protecting the airway, and preventing heat loss.
Assess the burn
Determine the mechanism, time of injury, enclosed-space exposure, chemical or electrical involvement, depth, location, and approximate extent. Also assess for associated trauma and respiratory problems. Burns involving the face or airway, circumferential burns, hands, feet, genitalia, major joints, large or deep burns, and electrical or chemical burns require particular concern.
For initial care, remove the patient from danger, remove jewelry and loose clothing near the burn, and leave material stuck to the skin in place. Cover the injury with a clean, dry, nonadherent dressing or sheet. Do not apply ice, butter, ointments, or other home remedies, and do not break blisters. Clean, cool running water may be appropriate for many minor thermal burns, but prolonged cooling of a large burn can worsen hypothermia.
Chemical burns require responder protection, removal of contaminated clothing, appropriate removal of dry chemicals before irrigation, and copious irrigation according to protocol and product safety information. For electrical injury, disconnect the power source before contact and assess for entrance and exit wounds, arrhythmia, burns, fractures, and deep tissue damage.
Recognize
An may follow an enclosed-space fire or exposure to smoke, steam, or toxic gases. Warning signs include facial burns, soot around the mouth or nose, hoarseness, stridor, coughing, singed facial hair, altered mental status, and increasing respiratory effort. Provide oxygen and support ventilation as needed, request advanced resources, and transport promptly because airway swelling may progress.
Takeaway: Airway and breathing concerns take priority over precise burn-size calculations, and extensive burns require aggressive prevention of heat loss.
Recognize Time-Critical Chest Trauma
Chest trauma can rapidly impair ventilation, oxygenation, or circulation. Treat airway and breathing problems immediately and look for patterns that require advanced intervention.
An open chest wound should be covered with a vented occlusive dressing when available, or an occlusive dressing secured according to local protocol. Monitor for worsening respiratory distress.
A flail segment is a portion of the chest wall that moves paradoxically because of multiple rib fractures. Support ventilation and oxygenation, but do not tightly bind the chest.
Suspect a with severe respiratory distress, markedly diminished or absent breath sounds on one side, worsening cyanosis, hypotension, distended neck veins, or late tracheal deviation. Request immediate advanced care and transport rapidly.
Hemothorax or internal chest bleeding may produce respiratory distress, shock, pale or cool skin, and decreased breath sounds.
Cardiac tamponade may occur after penetrating chest trauma and may be associated with hypotension, muffled heart sounds, and neck-vein distention, although the complete classic triad may be absent.
Minimize scene time when serious chest trauma is suspected. Provide oxygen or ventilatory support within protocol and continuously reassess respiratory effort, breath sounds, skin signs, and mental status.
Takeaway: Worsening respiratory distress after chest trauma is a transport and advanced-care priority, not a reason to prolong the on-scene examination.
Protect the Abdomen and Pelvis
Abdominal and pelvic injuries can cause severe internal hemorrhage even when external bleeding is minimal or absent.
Abdominal injury
Assess for pain, tenderness, guarding, rigidity, distention, bruising, penetrating wounds, evisceration, and shock. Do not palpate aggressively or push protruding organs back into the abdomen. With evisceration, cover the organs with a sterile dressing moistened with sterile saline and add an occlusive layer if permitted by protocol. Do not apply direct pressure to the exposed organs and do not give food or drink.
Pelvic injury
Pelvic fractures can produce life-threatening internal bleeding. Avoid repeatedly rocking or compressing the pelvis. Minimize movement, treat shock, and use a pelvic binder only when indicated and authorized by local protocol. Significant abdominal or pelvic trauma warrants consideration of a trauma-center destination and rapid transport.
Takeaway: Protect injured abdominal contents, avoid unnecessary manipulation, and assume serious internal bleeding is possible when shock accompanies abdominal or pelvic trauma.
Protect Musculoskeletal Function
Musculoskeletal care aims to control movement and pain while preserving circulation, motor function, and sensation. Assess the injured limb before and after every splinting intervention.
Fractures and joint injuries
A closed fracture does not break the skin. Support the limb and splint in the position found unless circulation is compromised or local protocol permits gentle realignment.
An open fracture requires a sterile dressing over the wound, bleeding control without pushing bone beneath the skin, and splinting.
A should be immobilized in the position found. Do not force the joint back into place.
A sprain or strain still requires assessment for fracture and neurovascular compromise.
Document distal pulse, motor function, sensation, color, temperature, and capillary refill when appropriate. Splinting should reduce movement and pain while preserving circulation; it must not delay airway, breathing, severe hemorrhage, or shock management.
Suspect when there is severe or increasing pain, pain with passive stretch, tense swelling, or neurologic change. This is a limb-threatening emergency requiring rapid transport.
Takeaway: A technically correct splint is less important than preserving distal neurovascular function and repeatedly reassessing it.
Evaluate Head and Spinal Injury
Head and spinal trauma require repeated neurologic assessment and protection from preventable secondary injury.
Head injury
Use a consistent mental-status scale, such as AVPU or the Glasgow Coma Scale when trained and equipped. Look for loss of consciousness, amnesia, vomiting, seizure, unequal pupils, worsening headache, confusion, agitation, weakness, blood or fluid from the ears or nose, raccoon eyes, Battle sign, and anticoagulant use.
A normal initial examination does not exclude serious brain injury. Maintain the airway, prevent hypoxia and hypotension, control external bleeding without excessive pressure over a suspected skull fracture, and transport promptly when concerning findings are present.
Spinal trauma
Consider spinal injury after significant blunt trauma, axial loading, high-energy mechanisms, falls, diving injuries, penetrating trauma near the spine, neurologic deficits, spinal tenderness, or altered mental status. Initially stabilize the head and neck manually when indicated. Apply based on the patient’s findings, local protocol, and medical direction.
Monitor for neck or back pain, midline tenderness, numbness, tingling, weakness, paralysis, loss of bowel or bladder control, abnormal posture, priapism, and respiratory difficulty suggesting a high cervical injury. If the patient must be moved because of danger, airway compromise, or inadequate breathing, use the safest available technique and limit unnecessary movement.
Takeaway: Airway and ventilation remain the priorities, while repeated neurologic checks help reveal deterioration that may not be obvious initially.
Recognize Shock and Make Transport Decisions
Trauma shock is frequently caused by bleeding until proven otherwise. Early recognition and prompt treatment are essential because hypotension is a late and dangerous sign.
Recognize
may begin with anxiety, restlessness, thirst, tachycardia, pale or cool skin, delayed capillary refill, and narrowing pulse pressure. Later findings can include hypotension, altered mental status, weak pulses, and collapse.
General EMT care includes:
Controlling external bleeding
Maintaining the airway and supporting breathing
Providing oxygen or ventilation according to clinical need and protocol
Keeping the patient warm
Positioning appropriately for the injury and breathing status
Avoiding food and drink
Reassessing vital signs and mental status
Requesting advanced care and transporting without unnecessary delay
Decide on transport urgency
Patients with uncontrolled hemorrhage, airway compromise, inadequate breathing, shock, altered mental status, serious chest trauma, suspected internal bleeding, major burns, or significant neurologic findings should not remain on scene for a prolonged secondary assessment. Local EMS systems and medical direction determine the exact destination and treatment pathway, including whether a trauma-center destination is appropriate.
Final takeaway: Trauma care is a cycle of safety, rapid assessment, immediate treatment, reassessment, and timely transport. Recheck the patient after every intervention and continue looking for deterioration.