Trauma Pathologies and Treatments (TRA)
Traumatic injuries are the most common and possibly the most graphic of conditions that the medical provider will face. Bleeding Control, bandaging, splinting, and wrapping are cornerstones of medical practice. This big idea encompasses all of those items along with shock identification and treatment, scene management, and rehabilitation.
TRA-1 Explain how to secure scene safety and build an initial impression.
TRA-1.A Describe the elements of a scene safety evaluation.
TRA-1.A.1 Explain the hierarchy of care (self, crew, bystanders, then patient).
TRA-1.A.2 Describe the possible threats and how to evaluate for each on a scene.
TRA-1.B Explain how to evaluate a scene for the determination of additional needed resources.
TRA-1.B.1 The first element is to evaluate the capacity of the team and compare that with the capacity needed.
TRA-1.B.2 The second element is identify any shortfall in capacity and request the resources to fill that gap.
TRA-1.C Describe the OODA loop of decision making and how to protect your OODA loop and utilize the concept for scene management.
TRA-1.C.1 The first step in the loop is Observe, this is where the individual becomes aware of the situation.
TRA-1.C.2 The second step in the loop is Orientate, this is where the individual is able to process the inputs and make sense of their place in the environment.
TRA-1.C.3 The third step in the loop is Decide, this is where the individual makes a decision to act.
TRA-1.C.4 The fourth step in the loop is Act, this is where the individual takes action.
TRA-1.C.5 The loop restarts with an observation of the results of the action.
TRA-2 Describe major categories of injuries.
TRA-2.A Describe muscular injuries
TRA-2.A.1 Explain overuse injury.
TRA-2.A.2 Explain deep muscular contusion.
TRA-2.A.3 Explain how strains are graded.
a. Describe Grade I Strains, which are stretching with small internal tears.
b. Describe Grade II Strains, which are larger but still incomplete tears.
c. Describe Grade III Strains, which are completely torn through the muscle.
d. Identify strains on imaging.
TRA-2.A.4 Describe a muscle rupture or when a fascia fails.
TRA-2.A.5 Explain compartment syndrome, rhabdomyolysis, and reperfusion injury.
a. Describe the components of compartment syndrome and what internal pressures are needed for it to occur.
b. Describe the chemical constituents of rhabdomyolysis and its symptomology of it.
TRA-2.B Describe tendon injuries
TRA-2.B.1 Explain how strains are graded.
a. Describe Grade I Strains, which are stretching with small internal tears.
b. Describe Grade II Strains, which are larger but still incomplete tears.
c. Describe Grade III Strains, which are completely torn through the tendon.
d. Identify strains on imaging.
TRA-2.B.2 Describe a tendon rupture or release from the attachment point. Explain the mechanism by which the bone will fail before the tendon.
TRA-2.C Describe ligament and cartilage injuries
TRA-2.C.1 Explain how the sprains are graded.
a. Describe Grade I Sprains, which are stretching with small internal tears.
b. Describe Grade II Sprains, which are larger but still incomplete tears.
c. Describe Grade III Sprains, which are completely torn through the tendon.
d. Identify sprains on imaging.
TRA-2.C.2 Describe the types of cartilage injuries in various locations in the body, especially in the knee.
TRA-2.D Describe bone fractures.
TRA-2.D.1 Explain the various types of fractures. Describe how two types can be combined.
a. Explain how a fracture can be open or closed.
b. Describe Greenstick incomplete fractures.
c. Describe Transverse complete and incomplete fractures.
d. Describe Spiral complete and incomplete fractures.
e. Describe Oblique complete and incomplete fractures.
f. Describe Compression complete and incomplete fractures.
g. Describe Comminuted complete and incomplete fractures.
h. Describe Segmental complete and incomplete fractures.
TRA-2.D.2 For each type of fracture, describe the energy and kinematics likely involved.
TRA-2.D.3 Explain the complications of a long bone fractures.
a. Describe how embolisms may arise from a fracture.
b. Describe how hypovolemic shock might arise from a fracture, include the amount of blood potential in each compartment.
c. Describe how a fracture might progress to a penetrating trauma of deep tissue.
d. Describe when surgical intervention may be needed.
TRA-2.D.4 Describe the energy needed to fracture specific bones.
TRA-2.E Describe burn injuries
TRA-2.E.1 Explain how burns are graded and the bullseye progression.
a. First Degree, Superficial, burns are defined as damage through the epi-dermis.
b. Second Degree, Partial Thickness, burns are defined as damage through the dermis.
c. Third Degree, Full Thickness, burns are defined as damage through the hypodermis.
d. Fourth Degree, Deep Tissue, burns are defined as damage into the organs and underlying muscle tissue.
TRA-2.E.2 Describe the difference between radiation burns, chemical burns, thermal burns, and electrical burns.
a. Explain the dosing for radiation burns and what the symptomology of various doses. Evaluate the amount of grays absorbed by various activities.
b. Explain the transfer of energy in a thermal burn and the determining factors in the severity of the thermal burn.
c. Explain the difference between acid and base burns along with redox burns.
d. Explain entry and exit point burns of electrical damage, explain the pathway burn.
e. For electrical burns evaluate the difference between resistance, amperage, and voltage along with the effects of each on burns.
TRA-2.E.3 Explain the characteristics of pattern burns and other burn evidence of abuse. Describe how to document these burns for reporting purposes.
TRA-2.E.4 Explain burns of social significance, why they are critical, and how they are treated.
TRA-2.E.5 Describe the operations of a burn unit in a trauma center.
a. Identify the various locations within the burn center and what takes place there.
b. Describe how burns centers are geographically distributed and how resources are allocated.
TRA-2.F Describe integumentary non-burn injuries
TRA-2.F.1 Explain the types of soft tissue integumentary injuries.
a. Explain amputations, both complete and incomplete.
b. Explain avulsions, both simple and complex.
c. Explain crush injury, and subdermal hematoma.
d. Explain punctures, with or without the foreign body still in place. Include punctures to the thorax and the special sensory organs.
e. Explain abrasions with or without foreign bodies imbedded in the abrasion.
f. Explain the differences between lacerations and incisions, including the objects that are likely to cause each.
g. Explain tears and evaluate which other injury they are a subset of.
TRA-2.F.2 Describe the various pathophysiology of blunt force and penetrating trauma.
TRA-2.G Describe blast injuries
TRA-2.G.1 Explain primary blast injuries.
TRA-2.G.2 Explain secondary blast injuries.
TRA-2.G.3 Explain tertiary blast injury
TRA-2.G.4 Explain quaternary blast injury.
TRA-2.G.5 Explain toxicokinetics of common substances released by an explosion.
TRA-2.H Describe concussions, include a description of the injury, recovery, and the processes involved.
TRA-2.H.1 Describe the energy (kw) needed to injure the brain.
a. Explain the power done to the brain (in kilowatts) in a single substantial impact.
b. Evaluate how many kilowatts are dangerous in a single impact.
c. Explain the cumulative effect of subclinical impacts. Identify the power done to the brain in various normal play actions.
d. Describe the amount of time needed to reset the condition of the brain.
TRA-2.H.2 Identify the symptomology of concussions.
a. Describe the ocular-vestibular reflex and how it is impacted by a concussion. Include proprioception, smooth pursuits, and saccades.
b. Describe the cognitive and emotional impacts of a concussion.
TRA-2.H.3 Explain the biochemical and microbiological injuries during a concussion.
a. Describe the transfer of K+ and Ca2+ ions in the neurons and the effects of this.
b. Explain the metabolic crisis within the neuron and how that leads to a massive release of neurotransmitters.
c. Describe how the neurometabolic cascade results in axonal injury, somatic injury, and/or cell death.
TRA-2.H.4 Explain diffuse axonal injuries.
a. Identify diffuse axonal injuries on imaging.
b. Describe the energy and pathogenesis of a diffuse axonal injury.
c. Describe the symptomology of a diffuse axonal injury and compare that to a concussion.
TRA-2.H.5 Describe the Return to School process.
a. Identify the Return to School process on the recovery timeline.
b. Describe the threshold needed to clear the Return to School process. Explain the obstacles to clearing Return to School and identify that a medical doctor (or D.O.) is the only person qualified to clear a student to Return to School.
c. Explain the academic accommodations during the Return to School process. Include the need to gradually remove accommodations as the patient progresses.
TRA-2.H.6 Describe the Return to Learn process.
a. Identify the Return to Learn process on the recovery timeline.
b. Describe the threshold needed to clear the Return to Learn process. Explain the obstacles to clearing Return to Learn and identify that a medical doctor (or D.O.) is the only person qualified to clear a student to Return to Learn.
c. Explain reasonable academic accommodations during the Return to Learn process. Describe the gradual release of accommodations as the patient recovers.
d. Evaluate why the student is prohibited from summative assessments during the Return to Learn process.
e. Describe how a 504 or I.E.P. can be used to permanently set a new a “new normal” for a patient to allow for summative assessments and allow for interscholastic athletics.
TRA-2.H.7 Describe the Return to Play process.
a. Identify the Return to Play process on the recovery timeline.
b. Explain why a student must be completely cleared Return to Learn before entering the Return to Play process.
c. Describe the threshold needed to enter the Return to Play process. Explain the obstacles to clearing Return to Play and identify that a medical doctor (or D.O.) is the only person qualified to clear a student in Return to Play.
d. Explain the stages of the Return to Play process and what is required to clear each stage including time frames.
e. Explain at what stage the patient is allowed to return to practice and matches.
TRA-2.H.8 Describe concussion sideline assessments and continuing reassessment.
a. Identify the signal behaviors or impacts that would require an assessment along with increased suspicion.
b. Describe the findings that would reduce spinal injury suspicion.
c. Explain how baseline mentation is determined, including: alertness, awareness, orientation, and Glasgow Coma Scale. Describe the need for rapid assessment and trending of mental status along with why this must be documented.
d. Explain how the eyes are assessed, including nystagmus, pupil reactivity, and ability to focus.
e. Explain how to assess for head wobble, including orbital, chaotic, and linear wobble.
f. Explain when it is safe to assess gait and how gait is assessed, including: drifting gait, slow gait, steppage gait, limping gait, and pathing (circular or chaotic).
g. Explain environmental sensitivity assessment, including photosensitivity, hyperacusis, hypoacusis, and temperature sensitivity.
h. Explain gastrointestinal assessment, including nausea, vomiting, fecal incontinence, and urine incontinence.
i. Describe the emotional changes that may or may not be present during post concussion assessment.
j. Identify the signs and symptoms that make a patient high risk and require immediate transport.
TRA-2.H.9 Explain chronic traumatic encephalopathy.
a. Describe the symptomology of chronic traumatic encephalopathy, including early and late signs. Also describe the possible co-morbidities to chronic traumatic encephalopathy including Parkinson’s disease, Creutzfeldt-Jakob disease, and Alzheimer’s disease.
b. Describe the difficulties of diagnosing chronic traumatic encephalopathy on imaging. Evaluate the usefulness of magnetic resonance imaging, nuclear magnetic resonance spectroscopy, CT scan, single-photon emission computed tomography, transcranial ultrasound, and positron emission tomography.
c. Evaluate the current research into the prevention of chronic traumatic encephalopathy.
TRA-2.I Describe organ injuries
TRA-2.I.1 Connect various common ailments to increased risk of organ damage in trauma.
TRA-2.I.2 Explain how each organ is damaged and the symptomology of that damage.
TRA-2.J Describe spinal injuries
TRA-2.J.1 Explain neurogenic shock and the mechanism for pathogenesis.
TRA-2.J.2 Explain dermatomes and the evaluation for the location of injury.
TRA-2.J.3 Explain incomplete spine injury, including anterior cord syndrome, central cord syndrome, and Brown-Sequard Syndrome.
TRA-2.J.4 Explain complete spine injury, including tetraplegia, paraplegia, and triplegia.
TRA-2.J.5 Explain subluxation, vertebral burst fracture, vertebral compression fracture, vertebral dislocation, and vertebral fracture-dislocation.
TRA-2.K Describe dehydration injury
TRA-2.K.1 Explain the hydration needs of the human body including how to calculate it for a specific athlete.
TRA-2.K.2 Describe the change in laboratory values during a dehydration event.
a. Explain the changes in Cl- during a dehydration event and what is a normal value.
b. Explain the changes in Na+ during a dehydration event and what is a normal value.
TRA-2.K.3 Describe how to rehydrate a patient. Evaluate when pure water versus electrolyte drinks.
TRA-2.K.4 Explain the symptomology of dehydration and how to assess for it.
TRA-2.L Describe envenomation injury
TRA-2.L.1 Explain the various locations and scenarios that would risk an envenomation.
TRA-2.L.2 Describe the various venomous and poisonous flora and fauna and their symptomology.
a. Explain rattlesnake strikes and its symptomology.
b. Explain coral snake strikes and its symptomology.
c. Explain black widow spider strikes and its symptomology.
d. Explain brown recluse spider strikes and its symptomology.
e. Explain bark scorpion strikes and its symptomology.
f. Explain American dog tick inbeds and its symptomology.
g. Explain gila monster strikes and its symptomology.
h. Explain California newt poisonings and its symptomology.
i. Explain yellow-bellied sea snake strikes and its symptomology.
j. Explain pacific poison-oak poisonings and its symptomology.
TRA-2.M Describe barometric/altitude injuries
TRA-2.M.1 Explain the increasing pressure found underwater.
TRA-2.M.2 Describe the pathophysiology of rapid decompression.
TRA-2.M.3 Explain the reduction of oxygen as one increases in altitude.
TRA-2.M.4 Describe the three types of high altitude injuries, including Acute Mountain Sickness, High Altitude Pulmonary Edema, and High Altitude Cerebral Edema.
TRA-2.M.5 Determine which co-morbities could be exacerbated by altitude and how to mitigate the effects of altitude changes.
TRA-2.N Describe hot and cold environmental injuries.
TRA-2.N.1 Describe how to evaluate the current and projected weather to give the coach an assessment of the health impact of the playing microclimate.
a. Describe how to evaluate the heat index for a given activity along with an evaluation of the playing surface microclimate.
b. Describe how to evaluate the wind chill index for a given activity along with an evaluation of the playing surface microclimate.
c. Explain the various levels of hazard “flags” and how to make a flag recommendation. These include: Green Flag (no impacts); Orange Flag (increased risk of environmental hazard, increase hydration but otherwise normal activities); Red Flag (institute excessive heat warning plan and limit activities); Black Flag (extreme risk, no outside activities or indoor activities without air conditioning).
TRA-2.N.2 Explain the symptomology and treatments of cold injuries.
a. Describe the difference between trench foot, frost nip, and frost bite.
b. Describe the appropriate treatment and mitigation strategies for trench foot, frost nip, and frost bite.
c. Describe and explain how to treat systemic hypothermia.
TRA-2.N.3 Explain the symptomology and treatments of heat injuries.
a. Describe the difference between heat exhaustion and heat stroke.
b. Describe the appropriate treatment and mitigation strategies for sunburn, heat exhaustion, and heat stroke.
TRA-2.O Describe the various toxidromes and human response to poisoning.
TRA-2.O.1 Explain the symptomology and causes of the anticholinergic toxidrome.
TRA-2.O.2 Explain the symptomology and causes of the cholinergic toxidrome.
TRA-2.O.3 Explain the symptomology and causes of the opioid toxidrome.
TRA-2.O.4 Explain the symptomology and causes of the sympathomimetic toxidrome.
TRA-2.O.5 Explain the symptomology and causes of the sedative-hypnotic toxidrome.
TRA-2.O.6 Describe the antidotes to the various toxidromes.
TRA-3 Describe the major trauma treatments, including recognition and treatment of shock.
TRA-3.A Explain bandaging and splinting techniques.
TRA-3.A.1 Describe bleeding control techniques.
TRA-3.A.2 Describe bandaging techniques and when each would be utilized.
TRA-3.A.3 Describe splinting techniques and when each would be utilized.
TRA-3.B Explain supportive wrapping techniques.
TRA-3.B.1 Describe the types of ankle wraps and when each would be utilized.
TRA-3.B.2 Describe the types of shin wraps and when each would be utilized.
TRA-3.B.3 Describe the types of extremity wraps and when each would be utilized.
TRA-3.B.4 Describe the types wrist and hand wraps and when each would be utilized.
TRA-3.B.5 Describe the types of abdominal and thoracic wraps and bandages along with each would be utilized.
TRA-3.B.6 Describe heat and cold wraps and when each would be utilized.
TRA-3.B.7 Describe ice application techniques and when it should be utilized.
TRA-3.C Explain burn treatment techniques.
TRA-3.C.1 Describe how to stop burning for each type of burn.
TRA-3.C.2 Describe how to manage burn injuries for each degree of burn.
TRA-3.C.3 Describe the parkland formula for fluid resuscitation.
TRA-3.C.4 Describe the criteria for burn center referral and burn center treatment.
TRA-3.D Explain c-spine immobilization techniques.
TRA-3.D.1 Describe the need for c-spine immobilization and the risks of the procedure.
TRA-3.D.2 Describe how to take manual in-line c-spine immobilization.
TRA-3.D.3 Describe how to secure the patient to a long spine board.
TRA-3.E Explain how to take vital signs and perform the primary and secondary survey.
TRA-3.E.1 Explain the acronym DCAP-BTLS and its utilization.
TRA-3.E.2 Describe the primary survey and when it should be conducted.
TRA-3.E.3 Describe the secondary survey and when it should be conducted.
TRA-3.E.4 Describe how to take vital signs and the normal ranges for each.
a. Explain and identify the critical values for each vital sign.
b. Explain what factors can lead to an inaccurate measurement.
TRA-3.F Describe the different types of shock, how to recognize them, and how to treat them.
TRA-3.F.1 Explain obstructive shock and its causes.
a. Obstructive shock is defined as a blockage that restricts blood flow.
b. Types of obstructive shock include pulmonary embolism and cardiac tamponade.
TRA-3.F.2 Explain distributive shock and its causes.
a. Distributive shock is defined as a loss of vascular tone or integrity leading to inability to maintain pressure and perfuse organs.
b. Types of distributive shock include septic shock, anaphylactic shock, neurogenic shock, burn induced shock, adrenal crisis, and hypoglycemia.
c. Explain the physiological cascade that causes the hypersensitivity reaction that can lead to anaphylactic shock. Explain the Hygiene Hypothesis and how it led to the surge in food allergies.
TRA-3.F.3 Explain hypovolemic shock and its causes
a. Hypovolemic shock is defined as a loss of circulating volume or a loss oxygen transport capacity.
b. This can include blood loss or anemia.
TRA-3.F.4 Explain the three phases of shock.
a. Describe compensated shock and its symptoms.
b. Describe decompensated shock and its symptoms.
c. Describe irreversible shock and its symptoms.
d. Describe the change in speed between phases as a patient ages.
TRA-3.F.5 Explain the treatment of shock.
a. Keep the patient warm during the treatment of shock.
b. Keep the patient supine with their feel slightly elevated.
c. Rapid transport and oxygen is indicated.
TRA-4 Identify and utilize appropriate rehabilitation strategies for common injuries.
TRA-4.A Describe stretching techniques and in what circumstances they would be utilized.
TRA-4.A.1 Explain the difference between dynamic and static stretching techniques. Evaluate when you would use either technique.
TRA-4.A.2 Describe the various types of stretches for each zone of the body.
a. Describe the stretches that a provider would use to provide flexibility to the lower body.
b. Describe the stretches that a provider would use to provide flexibility to the body’s core and hips.
c. Describe the stretches that a provider would use to provide flexibility to the upper body and neck.
TRA-4.B Explain the application of heat and cold in a therapeutic manner.
TRA-4.B.1 Justify the application of heat prior and during activity. Describe the indications and contraindications of heat applications.
TRA-4.B.2 Describe the application of ice.
a. Justify the restriction of ice till after the activity.
b. Describe how to apply an ice compress.
c. Describe how to use ice immersion therapy.
TRA-4.B.3 Explain how and why a provider would “hot wrap” an athlete’s extremity during practice or play.
TRA-4.C Describe the exercises to increase strength and flexibility.
TRA-4.C.1 Explain body strength exercises along with when and why they should be used.
TRA-4.C.2 Explain free weight exercises along with when and why they should be used.
TRA-4.C.3 Explain weight machines along with when and why they should be used.
TRA-4.D Explain the proper care and maintenance of stitches.
TRA-4.D.1 Describe the types and techniques of stitching.
TRA-4.D.2 Describe maintenance of stitches.
TRA-4.D.3 Describe how to remove stitches.
TRA-4.E Explain the proper technique and indications for massage.
TRA-4.E.1 Describe the different types of massage along with how, when, and why they should be used.
a. Explain and demonstrate the long, light strokes that are a part of Effleurage massage.
b. Explain and demonstrate the strong, long, gliding strokes that are a part of Swedish massage.
c. Explain and demonstrate the strong, short, deep strokes that are a part of Deep Tissue massage.
TRA-4.E.2 Describe the different types of liniments and when each one is indicated.
a. Explain the indications and contraindications for Skin Lubricant.
b. Explain the indications and contraindications for Cramergesic.
c. Explain the indications and contraindications for Atomic Balm.
TRA-5 Determine a transport decision for a given patient.
TRA-5.A Explain the high priority findings that would suggest emergent transport.
TRA-5.A.1 Remember that when in doubt, trust your gut, and error on the side of calling 911.
TRA-5.A.2 Identify the twelve findings that REQUIRE EMS activation. Note that this list is not all inclusive.
a. Activate EMS if the expert opinion of the staff EMS is needed
b. Activate EMS if there is CPR in progress.
c. Activate EMS if there is Altered Mental Status.
d. Activate EMS if there is any threat to a limb.
e. Activate EMS if there is any acute severe trauma.
f. Activate EMS if there is any suspected concussion.
g. Activate EMS if there is a seizure.
h. Activate EMS if there is an obstetrical emergency or issue.
i. Activate EMS if there is broken bone or dental emergency.
j. Activate EMS if there is a poisoning, envenomation, or overdose.
k. Activate EMS if there is suspected shock, including anaphylaxis.
l. Activate EMS if there is respiratory distress.
m. Activate EMS if the patient’s vital signs are at critical levels.
n. Activate EMS if the parents or guardians request it.
TRA-5.A.3 Explain the need that if time permits, contact should be made with the patient’s parent or guardian, even though it is not needed. Note: the life of the student should be preserved at all costs and even if the parents decline transport do not hesitate to activate EMS.
TRA-5.B Explain the various methods of transport and the restrictions of each.
TRA-5.B.1 Identify private transport options and the restrictions of each.
a. Explain family transport and when it should be used.
b. Explain self-transport and when it should be used.
c. Explain coach transport and when it should be used.
d. Explain peer / friend transport and when it should be used.
TRA-5.B.2 Identify EMS transport options and the restrictions of each.
a. Explain EMS ground transport options and the restrictions of each. Describe how to set up an ingress and egress zones.
b. Explain EMS air transport options and the restrictions of each. Differentiate between scene and rendezvous while describing how to set up a Landing Zone.
c. Explain when a backcountry or special EMS operation would be needed to assist and how aid the evacuation of the patient.
TRA-5.B.3 Describe the process for after EMS has been activated. This includes contacting Administration immediately and file an incident report with the patient’s coach or teacher.