Trauma
Mechanism, kinematics, and the platinum ten minutes.
High-yield before the exam
- Scene size-up first: a dead medic saves nobody. Gloves on, hazards called, number of patients estimated.
- Load-and-go criteria: unstable airway, shock, chest/abdominal penetrating trauma, ejection, high-fall mechanism.
- Permissive hypotension in penetrating torso trauma: titrate fluids to a radial pulse / mentation, not a 'normal' BP.
- Tension pneumothorax: unilateral absent sounds + JVD + hypotension + tachycardia → needle decompression now.
- Head injury: avoid hypoxia AND hyperventilation; brief hyperventilation only for herniation signs (blown pupil, posturing).
Drug cards3
Dose: 1 mcg/kg IV/IN (typically 50–100 mcg), repeat per protocol.
Indications
- Ischemic chest pain unrelieved by nitrates
- Severe traumatic or burn pain
- Sedation adjunct
Cautions
- Respiratory depression
- Hypotension in the volume-depleted
- Chest-wall rigidity with rapid large doses
SLOW + LOW
- Titrate small and reassess
- Watch the respiratory rate and ETCO₂
- Naloxone and a BVM at the bedside
Pearl: Fentanyl is hemodynamically kinder than morphine in cardiac patients — less histamine, less preload dump.
Dose: Pain: 0.1–0.3 mg/kg IV. Sedation for procedures: 1–2 mg/kg IV. Excited delirium: 4–5 mg/kg IM.
Indications
- Analgesia without blood-pressure collapse
- Sedation for cardioversion or pacing
- Severe agitation / excited delirium
Cautions
- Emergence reactions — keep the room calm
- Increases secretions and heart rate
- Laryngospasm is rare but real
K-HOLE
- K — Keeps respirations and pressure
- Dissociation not deep sleep
- Small doses for pain, big doses for sedation
Pearl: The analgesic for the hypotensive trauma or cardiac patient — it supports blood pressure instead of stealing it.
Dose: 1 g IV over 10 minutes, within 3 hours of injury.
Indications
- Significant traumatic hemorrhage
- Postpartum hemorrhage per protocol
Cautions
- Useless after 3 hours from injury
- Give slowly — fast push drops pressure
- Not a substitute for bleeding control and plasma
3 HOURS
- T — Time matters most
- X — eXtra help for clots
- A — After 3 hours, skip it
Pearl: TXA does not make clots — it stops the body from dissolving the ones it already made. Pressure first, TXA second.
Rhythms to know5
Sinus Tachycardia · 100–150
- P before every QRS
- Regular
- Gradual onset
Action: Find and fix the why: pain, fever, hypovolemia, hypoxia.
Atrial Fibrillation (RVR) · Variable, often > 100
- No P waves
- Irregularly irregular
- Fibrillatory baseline
Action: Stable → rate control. Unstable → synchronized cardioversion.
Ventricular Tachycardia · 100–250
- Wide, bizarre QRS
- Regular
- No P waves
Action: Pulse + stable → amiodarone. Pulse + unstable → sync. No pulse → defibrillate.
Ventricular Fibrillation · Chaotic
- No identifiable waves
- Chaotic baseline
- No pulse
Action: CPR + defibrillate now. Epi q3–5, amio 300 after 3rd shock.
PEA · Any organized rate
- Organized complexes
- No pulse
- Often wide and slow
Action: CPR + epi + reversible causes. Not shockable.
Field cases1
Blunt trauma with obvious pelvic instability and a large thigh hematoma. Bleeding controlled with direct pressure.
Vitals: BP 84/50 · HR 132 · RR 28 · SpO₂ 93% RA
Monitor: Sinus tachycardia at 132. Cool, mottled skin, delayed capillary refill.
Skills to drill4
Assessment & vitals
Mastery: Full head-to-toe with lung sounds, pupils, and skin in under 3 minutes, trending not snapshotting.
Drill: Practice a 90-second rapid trauma and a 3-minute medical assessment until narrated smooth.
History taking (OPQRST/SAMPLE)
Mastery: Pulls a complete history from a scared patient in plain language, and hears what is not said.
Drill: Role-play with a partner who answers evasively — get the whole SAMPLE anyway.
Scene safety & size-up
Mastery: Reads the scene before the patient: hazards, mechanism, number of patients, resources needed.
Drill: On every arrival, say your size-up out loud before touching anyone. Every time.
Lifting & moving
Mastery: Power lifts, stair chair, and draw-sheet moves with zero back strain — for a 30-year career.
Drill: Practice the stair chair with a partner monthly; legs lift, back stays locked.
Board-style exam questions44
1. Tension pneumothorax field treatment?
2. Uncontrolled arterial bleeding from a thigh laceration. First action?
3. Cushing's triad indicates:
4. Permissive hypotension in penetrating torso trauma targets roughly:
5. Best position for a hypotensive pregnant trauma patient immobilized on a board?
6. Burn patient with singed nasal hairs, soot and hoarseness. Priority?
7. Flail chest is best managed prehospital with:
8. Adult trapped by a crushed extremity for 4 hours. Greatest arrest risk at extrication?
9. Estimated burn surface area for an adult with the entire anterior torso burned (rule of nines)?
10. Open (sucking) chest wound management?
11. Which finding best identifies compensated shock early?
12. Impaled object in the abdomen. Correct management?
13. Pelvic fracture with hypotension after a motorcycle crash. Priority intervention?
14. Spinal motion restriction is most clearly indicated for:
15. TBI patient with a GCS of 7. Ventilation target?
16. Amputated finger care during transport?
17. Best field control for severe extremity arterial bleeding?
18. Permissive hypotension in penetrating torso trauma targets:
19. Cushing's triad indicates:
20. Ventilation goal in severe traumatic brain injury without herniation signs?
21. Open chest wound with bubbling. Apply:
22. Suspected pelvic fracture with hypotension. Do:
23. Burn patient with singed nasal hair, soot and hoarseness. Priority?
24. Adult with burns to the entire anterior torso and one full arm. Rule-of-nines estimate?
25. Crush injury with prolonged entrapment. Anticipate:
26. Impaled object in the abdomen should be:
27. Spinal motion restriction is indicated when:
28. Tranexamic acid in hemorrhagic trauma is most effective when given:
29. A flail chest segment is suspected. The primary life threat to manage is:
30. In a multisystem trauma patient, which injury is managed FIRST?
31. Neurogenic (spinal) shock differs from hypovolemic shock by:
32. An evisceration with bowel protruding should be covered with:
33. A patient bleeding from a scalp laceration is confused, vomits twice and has one dilated pupil. Most likely problem?
34. Two-person log-roll of a supine trauma patient should be directed by:
35. A hypotensive patient with a femur fracture should receive a traction splint primarily to:
36. The triad of damage-control priorities in a severely bleeding trauma patient is to prevent:
37. A child struck by a car has a normal blood pressure, a heart rate of 160 and delayed capillary refill. This represents:
38. Waddell triad in a child struck by a vehicle involves injuries to:
39. Neurogenic shock after a high cervical injury classically presents with:
40. Tranexamic acid is most beneficial in hemorrhagic trauma when given:
41. Which burn is immediately transported to a burn center?
42. Traction splinting is contraindicated with:
43. Suspected child abuse is suggested by:
44. Priority for a patient with evisceration of abdominal contents?
Keep going
Educational review only — always follow your local protocols and medical direction. Not affiliated with or endorsed by the NREMT.