Severe external bleeding is first controlled with direct pressure on the wound. When life-threatening extremity hemorrhage cannot be controlled this way, a tourniquet is applied 2–3 inches proximal to the wound, never over a joint. Hemorrhagic shock is classified by the percentage of blood loss: Class I (less than 15%), Class II (15–30%), Class III (30–40%), and Class IV (greater than 40%). Compensated shock presents early with tachycardia, pale/cool/clammy skin, anxiety, and delayed capillary refill, while decompensated shock shows hypotension, altered mental status, weak or absent peripheral pulses, and cyanosis. The EMT's primary treatment for all forms of shock includes high-flow oxygen, warmth, bleeding control, and rapid transport; a patient without spinal or leg injury may be placed supine with legs elevated to improve perfusion. Beyond hypovolemia, shock can arise from anaphylaxis (severe allergic reaction with widespread vasodilation and airway swelling, treated with epinephrine auto-injector), neurogenic injury (spinal cord damage producing warm skin and hypotension without tachycardia), cardiogenic failure (the heart's inability to pump effectively, often after MI), and sepsis (severe infection causing vasodilation and organ dysfunction).
Thoracic trauma includes several life-threatening conditions. A tension pneumothorax occurs when air accumulates in the pleural space, causing lung collapse and shifting of mediastinal structures; signs include severe respiratory distress, absent breath sounds on one side, tracheal deviation, jugular vein distension, and hypotension. Flail chest results from two or more ribs fractured in two or more places, creating a paradoxical-moving segment that is best managed with positive pressure ventilation and high-flow oxygen. An open or sucking chest wound is treated with an occlusive or vented chest seal to prevent air entry. Other traumatic findings include crepitus, a grating sensation from broken bone ends, an impaled object, which should be stabilized in place unless it obstructs the airway or interferes with CPR, and eviscerations, or protruding organs, which are covered with a moist sterile dressing and an occlusive outer layer, never pushed back in.
Burn management begins with stopping the burning process, removing smoldering clothing and jewelry, and covering with a dry sterile dressing. EMTs should never apply ice, butter, ointments, or ice-cold water due to hypothermia risk and potential further tissue damage. Burns are classified by depth: superficial (first-degree) burns are red and painful without blistering; partial-thickness (second-degree) burns show blistering, moist red or mottled skin, and significant pain; full-thickness (third-degree) burns appear charred, white, or leathery and may be painless due to nerve destruction. The Rule of Nines estimates burn extent in adults (each arm 9%, each leg 18%, anterior trunk 18%, head 9%), while infants use a modified rule with the head representing 18% of total body surface area. Chemical burns require brushing off dry chemicals first, then flushing with copious water for at least 20 minutes.
Spinal trauma requires manual stabilization of the head and neck in a neutral in-line position as soon as possible. Signs of spinal cord injury include numbness, tingling, paralysis, or loss of sensation or motor function below the injury site. Cushing's triad, consisting of rising blood pressure, decreasing heart rate, and irregular respirations, is a late indicator of increased intracranial pressure. Basilar skull fractures may present with Battle's sign (bruising behind the ears), raccoon eyes (bruising around the eyes), or cerebrospinal fluid leakage from ears or nose. Suspected fractures are splinted by immobilizing the joint above and below the injury, and distal pulse, motor function, and sensation (PMS) are checked before and after splinting. Compartment syndrome is suggested by severe pain out of proportion to injury, tightness, pallor, paresthesia, and late pulselessness. An amputated body part is wrapped in sterile dressing, placed in a plastic bag, kept cool on ice without direct contact, and transported with the patient. The golden hour concept emphasizes that definitive trauma care within the first hour of severe injury improves survival.