ITLS/PHTLS Approach · Head/Spinal/Thoracic/Abdominal Trauma · Burns · Pediatric · EMS Operations | The Firefighter Medic
| Parameter | Normal | Critical Threshold |
|---|---|---|
| GCS | 15 | <8 = consider definitive airway |
| Systolic BP (adult) | 100–140 mmHg | <90 = shock; penetrating trauma target 80–90; TBI target >110 |
| SpO2 | 95–100% | <90% = hypoxia |
| EtCO2 | 35–45 mmHg | <25 = hyperventilation; >50 = hypoventilation |
| Pediatric ET tube (uncuffed) | — | (Age/4) + 4; cuffed: (Age/4) + 3.5 |
| Parkland Formula | — | 4 mL × kg × %TBSA; first half in 8h from injury |
Deformities · Contusions · Abrasions · Punctures/Penetrations · Burns · Tenderness · Lacerations · Swelling
💡 Kinematics: Velocity matters MORE than mass — doubling speed quadruples kinetic energy (½mv²). Internal organs continue moving after the body wall stops → deceleration injuries (aortic tear, liver laceration).
CPP = MAP – ICP · Normal CPP: 60–70 mmHg · Target in TBI: Keep MAP high, keep ICP low · SBP target in severe TBI: >110 mmHg
| Type | Location | Classic Presentation | CT Finding |
|---|---|---|---|
| Epidural Hematoma | Between skull and dura (arterial) | "Lucid interval" → rapid deterioration | Biconvex (lens-shaped) |
| Subdural Hematoma | Between dura and brain (venous) | Gradual onset (hours to weeks) | Crescent-shaped |
| Subarachnoid | Subarachnoid space | "Worst headache of my life" (thunderclap) | Diffuse blood in sulci |
⚠️ Exam Trap: Prophylactic hyperventilation is HARMFUL — causes cerebral vasoconstriction and worsens ischemia. Hyperventilation (EtCO2 30–35) is ONLY for ACTIVE HERNIATION (blown pupil + Cushing's triad) as a temporary bridge. Normocapnia for all other TBI.
| Syndrome | Description | Key Finding |
|---|---|---|
| Complete | Total loss of function below level | No motor or sensory |
| Anterior Cord | Motor loss, pain/temp loss; preserved proprioception/vibration | Flexion injury (burst fracture) |
| Central Cord | Weakness worse in arms > legs | Hyperextension in elderly ("arms worse than legs") |
| Brown-Séquard | Hemisection — ipsilateral motor loss, contralateral pain/temp loss | Penetrating trauma |
Neurogenic Shock: Disruption of sympathetic pathways (T6 and above) → loss of vasomotor tone + bradycardia. Presentation: Hypotension + Bradycardia + Warm, dry, pink skin. Treatment: IV fluids (cautious), vasopressors (norepinephrine), atropine for bradycardia.
Spinal Shock: NOT a hemodynamic condition — temporary loss of ALL reflexes below level of injury. Flaccid paralysis initially → spasticity returns as shock resolves.
⚠️ Exam Trap: Trauma patient with hypotension + BRADYCARDIA + warm skin after MVC = neurogenic shock, NOT hypovolemic shock (which has tachycardia). Bradycardia with hypotension is the key distinguishing sign.
| # | Injury | Key Signs | Field Treatment |
|---|---|---|---|
| 1 | Tension Pneumothorax | Absent breath sounds, JVD, hypotension, tracheal deviation (LATE) | Needle decompression immediately — 2nd ICS, MCL |
| 2 | Open Pneumothorax | Sucking chest wound, SpO2 drop | Vented (3-sided) occlusive dressing |
| 3 | Massive Hemothorax | Shock + dullness to percussion + absent breath sounds + FLAT JVD | IV access, fluid resuscitation, rapid transport |
| 4 | Flail Chest | Paradoxical chest wall movement, severe respiratory distress | Positive pressure ventilation (CPAP or IPPV) |
| 5 | Cardiac Tamponade | Beck's triad: hypotension + JVD + muffled heart sounds | IV fluids (temporizing), pericardiocentesis per protocol, rapid transport |
| 6 | Aortic Disruption | Deceleration MOI, interscapular pain, differential pulses/BP | Hospital only — no field intervention |
⚠️ Open Pneumo Trap: A fully occlusive (4-sided) dressing without a vent can convert an open pneumo to a TENSION pneumo. Use vented (3-sided) seal. If patient deteriorates after sealing → lift corner to burp air, then needle decompress if needed.
⚠️ Flail Chest Trap: Sandbag/tape splint is outdated. POSITIVE PRESSURE (CPAP or intubation) is the treatment — it splints from inside. The underlying pulmonary contusion is the greater danger.
⚠️ Tension vs. Hemothorax: Tension = JVD elevated. Massive hemothorax = JVD FLAT (losing blood). Don't needle decompress a hemothorax — it won't help blood.
Solid Organs (Liver, Spleen, Kidneys, Pancreas): Highly vascular → bleed profusely. Kehr's sign = left shoulder pain from splenic hematoma irritating diaphragm. "Solid organs bleed" → hemorrhagic shock is the danger.
Hollow Organs (Stomach, Intestine, Bladder): Don't bleed much initially. Spillage of contents → peritonitis (delayed hours to days). Board-like rigidity develops over time. "Hollow organs perforate" → peritonitis/sepsis is the delayed danger.
Pelvic fractures can cause 3–4L+ blood loss. Signs: instability on compression (do ONCE — no repeated rocking), leg length discrepancy, hemorrhagic shock without obvious external bleeding.
⚠️ Pelvic binder at GREATER TROCHANTERS — not iliac crests. This is a frequently tested exam point.
Tourniquet preferred. Preserve amputated part: wrap in moist sterile gauze → sealed bag → bag on ice (do NOT put part directly in ice water — frostbite). Replantation viability: <6h warm ischemia; <12h cold ischemia.
⚠️ Compartment Syndrome Trap: "Pain with passive stretch" = earliest and most reliable sign. Pulselessness = LATE and means irreversible damage. Femur fracture = 1–1.5L blood loss into thigh alone.
| Degree | Appearance | Pain | Treatment |
|---|---|---|---|
| 1st (Superficial) | Red, dry, no blisters | Painful | Cooling, moisturize; NOT counted in BSA |
| 2nd (Partial Thickness) | Blisters, moist, red/pink | Very painful | Wet dressing, early debridement |
| 3rd (Full Thickness) | White/brown/black, leathery, dry | Painless (nerve destruction) | Skin grafting |
| 4th (Deep Full Thickness) | Involves bone/muscle/tendon | Painless | Amputation/major reconstruction |
Signs: singed nasal hairs/eyebrows, soot in mouth/nares, hoarseness, stridor, burns to face/neck, enclosed space fire history.
⚠️ Intubate EARLY in suspected inhalation injury — before edema makes the anatomy unrecognizable. SpO2 97% is FALSELY REASSURING in CO poisoning. Aggressive early intubation is always the correct NREMT answer for hoarseness + inhalation mechanism.
| Feature | Child vs. Adult | Clinical Impact |
|---|---|---|
| Head size | Proportionally larger | Greater risk of head injury; prone to head-first impacts |
| Chest wall | More compliant (cartilaginous ribs) | Pulmonary contusion WITHOUT rib fractures |
| Liver/spleen | More exposed (less thoracic coverage) | Higher solid organ injury risk |
| Blood volume | 70–80 mL/kg (smaller total) | Small absolute blood loss = significant relative loss |
Children compensate EXTREMELY WELL — maintain normal BP until decompensation is sudden and catastrophic. Tachycardia is the EARLIEST sign of shock in children. Hypotension is a LATE, pre-arrest sign.
⚠️ Your role: Document objectively, report to hospital, follow mandatory reporting laws. Do NOT confront caregiver on scene (safety risk, evidence preservation).
| Medication | Effect | Clinical Impact |
|---|---|---|
| Beta-blockers | Block tachycardia response | HR stays low even in hemorrhagic shock (masking) |
| Anticoagulants (Warfarin, NOACs) | Impaired clotting | Intracranial bleeds extend; major hemorrhage harder to control |
| Aspirin/NSAIDs | Platelet dysfunction | Increased bleeding risk |
| Diuretics | Relative hypovolemia | Less volume reserve; dehydration baseline |
| ACE inhibitors/ARBs | Blunted vasoconstriction | Less compensatory vasoconstriction in shock |
⚠️ Exam Trap: Elderly patient on metoprolol with HR 72 and BP 90/60 after fall = SHOCK masked by beta-blocker. The expected tachycardia is pharmacologically blocked. ALWAYS get a medication history. Brain atrophy in elderly = large subdural hematoma before symptoms develop — STRONGLY urge transport for any head injury.
| Feature | Heat Exhaustion | Heat Stroke |
|---|---|---|
| Temperature | Normal or <104°F | >104°F — often >106°F |
| Mental Status | Normal to mild confusion | Altered, confused, coma |
| Skin | Cool, pale, moist | Hot, dry (classic) OR moist (exertional) |
| Urgency | Rehydrate and treat | IMMEDIATE life threat — cool NOW |
Heat Stroke Treatment: Remove from hot environment → aggressive cooling NOW (ice packs neck/axillae/groin, wet towels, cold IV fluids) → high-flow O2 → protect airway (AMS = aspiration risk) → NO antipyretics (not a fever) → rapid transport
| Stage | Core Temp | Features | Treatment |
|---|---|---|---|
| Mild | 32–35°C | Shivering, tachycardia, impaired judgment | Remove wet clothing, passive rewarming |
| Moderate | 28–32°C | Shivering STOPS, bradycardia, atrial dysrhythmias | Active external rewarming (warm blankets, heat packs) |
| Severe | <28°C | No shivering, V-fib risk, coma | Active internal rewarming (hospital — warm IVF, airway warming, ECMO) |
⚠️ "No one is dead until they are warm and dead." V-fib in hypothermia may not respond to defibrillation until core temp >30°C. Lightning injury = REVERSE TRIAGE — those who appear dead (cardiac arrest) are your highest priority, not the walking wounded.
Same as START with key modification: If not breathing after repositioning → give 5 rescue breaths. If now breathing → Red. If still not breathing → Black. Normal RR for pediatric: 15–45.
| Color | Category | Action |
|---|---|---|
| RED | Immediate | Life-threatening, treatable — treat now |
| YELLOW | Delayed | Serious but stable — can wait 30–60 min |
| GREEN | Minor | Walking wounded — treat last |
| BLACK | Expectant/Dead | Dead or unsurvivable — no resources |
⚠️ CBRN Nerve Agent: Rapid-onset cholinergic syndrome (SLUDGE: Salivation, Lacrimation, Urination, Defecation, GI distress, Emesis) + muscle paralysis + bradycardia = nerve agent (Sarin, VX). Treatment: Atropine (large doses) + Pralidoxime + Diazepam for seizures.