BTLS

Guruh Wirasakti
Trauma Care

• Teamwork is important!
• You must know:
1. What you can handle and what you can’t
2. What you should handle and what you
shouldn’t
3. When to stay and when to leave
4. Fastest route there and fastest route away
5. What to do, what not to do, and when to wai
 Scene Size-up

• Standard precautions
• Scene safety
• Initial triage (total number of
patients)
• Need for more help or
equipment
• Mechanism of injury

BTLS Primary Survey

Initial Assessment

• General impression
• Initial level of consciousness
• Manual stabilization of cervical
spine
• ABCs

Mechanism
of Injury

Rapid Trauma Survey Focused Exam

Load-and-
Go
Situations

Secondary Survey Ongoing Exam

 Scene Size-up

Scene Size-up • Standard precautions

• Scene safety
• Initial triage (total number of
patients)
• Need for more help or
equipment
• Mechanism of injury

BTLS Primary Survey

Initial Assessment

• General impression
• Initial level of consciousness
• Manual stabilization of cervical
spine
• ABCs

Mechanism
of Injury

Rapid Trauma Survey Focused Exam

Load-and-
Go
Situations

Secondary Survey Ongoing Exam

Scene Size-up

• A critical part of trauma assessment

• Anticipate what you will find at scene
• Anticipate equipment and resource needs
• Form a plan of approach
• Be prepared to modify that plan
• Failure to size-up can jeopardize lives.
Scene Size-up

 First step in BTLS Primary Survey

Scene Size-up

1. Standard precautions
2. Scene safety
3. Initial triage (total number of patients)
4. Need for more help or equipment
5. Mechanism of injury
Standard Precautions

Personal protective equipment is

always needed at trauma scenes.
 Scene Safety

 Ambulance positioning
1. Safe place to park
2. Facing away from scene
 Windshield survey
1. Threats to you
2. Threats to/from patient
3. Threats to/from bystanders
Initial Triage

 Total number of patients

 Call for backup
 Medical command
 Initiate MCI protocols
 Any more patients?
Need for More

 Essential equipment
 Carry to scene for time efficiency
 Change gloves between patients
 Additional resources
 Call early
Mechanism of Injury

 Energy follows physics laws.

Injuries present in predictable patterns
 High-energy at risk for severe injury.
Consider injured until proven otherwise
 Factors to consider:
1. Direction and speed of impact, patient
kinetics and physical size, signs of energy
release
Basic Motion Mechanisms

 Blunt injuries
1. Rapid forward deceleration
2. Rapid vertical deceleration
3. Blunt instrument energy transfer

 Penetrating injuries
1. Projectiles
2. Knives
3. Falls upon objects
Pedestrian Injuries

 Mechanism
1. Primary collision
2. Additional impacts

 Common injuries
1. Severe internal injuries and fractures
2. Adult: bilateral leg, knee
3. Child: pelvis, torso
Penetrating Injuries

Knife-wound severity
 Anatomic area penetrated
Fourth intercostal space may be chest and
abdomen
 Length of blade
 Angle of penetration

Stabilize impaled object

 Minimize external movement
Blast Injuries

 Primary
Initial air blast
 Secondary
Material propelled
 Tertiary
Impact on object
 Quaternary
Dispersed hazardous
 Caution
Do not approach until
Scene Size-up is complete!
 Scene Size-up

Assessment • Standard precautions

• Scene safety
and Initial Management • Initial triage (total number of
patients)
of the Trauma Patient • Need for more help or
equipment
• Mechanism of injury

BTLS Primary Survey

Initial Assessment

• General impression
• Initial level of consciousness
• Manual stabilization of cervical
spine
• ABCs

Mechanism
of Injury

Rapid Trauma Survey Focused Exam

Load-and-
Go
Situations

Secondary Survey Ongoing Exam

BTLS Primary Survey

BTLS Primary Survey

 Scene Size-up
 Initial Assessment
 Rapid Trauma Survey or Focused Exam
BTLS Primary Survey

Initial Assessment
 General impression
 Initial level of consciousness
 Manual stabilization of cervical spine
 ABCs

Prioritizes patient
 Determines existence of immediately life
threatening conditions
BTLS Primary Survey

Less than 2 minutes

 Initial Assessment and Rapid Trauma Survey
Delegate any intervention.
 Interrupt survey only for:

Scene danger
Airway obstruction
Cardiac arrest
BTLS Primary Survey

General impression
 Approximate age, sex, weight
 General appearance
 Position of patient body and surroundings
 Patient activity
 Obvious major injuries or bleeding

Triage patients rapidly, if necessary.

BTLS Primary Survey

Initial Level of Consciousness

 Cervical-spine stabilization
BTLS Primary Survey

Airway: look, listen, feel

 Direct: simple positioning and suctioning

If not adequate, not quickly correctable

 Interrupt: advanced airway techniques
BTLS Primary Survey

Breathing: look, listen, feel

 Direct: high-flow oxygen
If not adequate
 Direct: assisted ventilation
BTLS Primary Survey

Circulation: peripheral pulse

 No peripheral, check carotid
 Too fast, too slow, quality
 Interrupt: cardiac arrest

Skin
 Color, temperature, condition

Major bleeding scan

 Direct: bleeding control
MOI Decision

Dangerous generalized or unconscious

 Rapid Trauma Survey

Dangerous focused
 Focused Exam

Not significant
Initial Assessment normal
 Focused Exam
Priority Patient

 Dangerous MOI

 History
1. Loss of consciousness
2. Difficulty breathing
3. Severe pain in head, neck, torso

 High-risk group
1. Altered mental status
2. Difficulty breathing
3. Abnormal perfusion
4. Abnormal Initial Assessment
 Scene Size-up

• Standard precautions
Rapid Trauma Survey • Scene safety
• Initial triage (total number of
patients)
• Need for more help or
equipment
• Mechanism of injury

BTLS Primary Survey

Initial Assessment

• General impression
• Initial level of consciousness
• Manual stabilization of cervical
spine
• ABCs

Mechanism
of Injury

Rapid Trauma Survey Focused Exam

Load-and-
Go
Situations

Secondary Survey Ongoing Exam

Rapid Trauma Survey

 Inspect Head and Neck

1. Major Facial Injuries, Bruising, Swelling, Penetrations,
2. Subcutaneous Emphysema
3. Neck Vein Distention? Tracheal Deviation?

 Inspect Chest
1. Asymmetry, Contusion, Penetrations,
2. Paradoxical Motion, Instability, Crepitation
3. Breath Sounds
Present? Equal?
(If unequal: Percussion)
1. Heart Tones
Rapid Trauma Survey
 Abdomen
1. Bruising, Penetration/Evisceration, Tenderness, Rigidity,
2. Distention

 Pelvis
1. Tenderness, Instability, Crepitation

 Lower/Upper Extremities
1. Swelling, Deformity, Instability, Motor, Sensory
2. Place Patient on Backboard

 Posterior
1. Penetrations, Deformity, Presacral Edema
Rapid Trauma Survey

If critical situation, transfer to

ambulance to complete exam
Rapid Trauma
Survey

 Baseline Vital Signs

Measured Pulse, Respirations, Blood Pressure

 Pupils
Size? Reactive? Equal?
(If Altered Mental Status:)

 Glasgow Coma Scale Score

Eyes, Voice, Motor, Orientation, Emotional State
Brief Targeted History

 S= Symptoms
 A = Allergies
 M = Medications
 P = Past medical history
 L = Last oral intake
 E = Events preceding incident
Load-and-Go Situations

 Initial Assessment
1. Altered mental status
2. Abnormal respiration
3. Abnormal circulation

 Shock potential
1. Abnormal chest exam
2. Tender, distended abdomen
3. Pelvic instability
4. Bilateral femur fractures
When in doubt—transport early!
Critical Interventions

On-scene procedures
 Manage airway  Seal sucking chest
 Assist ventilation  Stabilize flail chest
 Administer oxygen  Decompress tension
pneumothorax
 Begin CPR
 Stabilize impaled
 Control major external
bleeding  Complete packaging
Initiate Transport

Procedures not on scene, not life-saving

 Splinting, bandaging, IV line insertion
 Endotracheal intubation, often

Contact medical direction

 As early as possible
 Estimated time of arrival (ETA)
 Condition of patient
 Special needs on arrival
 Scene Size-up

BTLS Secondary • Standard precautions

• Scene safety

Survey
• Initial triage (total number of
patients)
• Need for more help or
equipment
• Mechanism of injury

BTLS Primary Survey

Initial Assessment

• General impression
• Initial level of consciousness
• Manual stabilization of cervical
spine
• ABCs

Mechanism
of Injury

Rapid Trauma Survey Focused Exam

Load-and-
Go
Situations

Secondary Survey Ongoing Exam

BTLS Secondary Survey

More comprehensive exam

 Evaluation for all injuries, not just life-threatening
 Establishes baseline for treatment decisions

Performed
 Critical patients—done during transport
 Short transport—may not have time
 Non-critical patients—done on scene
BTLS Secondary Survey

Initial Assessment
 Repeat routinely

Vital signs
 Repeat routinely
 Monitoring

Detailed Exam
 • Head-to-toe
 • DCAP-BTLS
BTLS Secondary Survey

INITIAL ASSESSMENT
 LOC
 AVPU
 Airway
1. Control Cervical Spine
2. Snoring, Gurgling, Stridor, Silence
 Breathing
1. Present? Rate, Depth, Effort
 Carotid/Radial Pulses
1. Present? Rate, Rhythm, Quality
2. Skin Color, Temperature, Moisture; Capillary Refill
3. Uncontrolled External Hemorrhage?
Detailed Exam: DCAP-BTLS

 Deformities
 Contusions
 Abrasions
 Penetrations
 Burns
 Tenderness
 Lacerations
 Swelling
BTLS Secondary Survey

DETAILED EXAM
 Patient History
 Complete SAMPLE History
 Vital Signs
1. Measured Pulse, Respirations, Blood Pressure,
SpO2
2. ECG, Blood Sugar, EtCO2
 Glasgow Coma Scale Score
1. Eyes, Voice, Movement; Emotional State
 Head
1. Pupils, Battle’s Sign, Raccoon Eyes, Drainage;
2. DCAP-BTLS
BTLS Secondary Survey

 Neck
1. DCAP-BTLS; Neck Vein Distention? Tracheal
Deviation?
 Chest
1. Asymmetry; Paradoxical Motion; DCAP-BTLS;
Tenderness, Instability, Crepitation [TIC]
2. Breath Sounds : Present? Equal?
(If unequal: Percussion)
3. Heart Tones
BTLS Secondary Survey

 Abdomen
1. DCAP-BTLS; Rigidity, Distention
 Pelvis
1. DCAP-BTLS
 Lower/Upper Extremities
1. DCAP-BTLS; TIC; PMS
 Posterior
1. Examine only if not done in BTLS Primary
Survey
2. DCAP-BTLS
 Scene Size-up

• Standard precautions
BTLS Ongoing Exam • Scene safety
• Initial triage (total number of
patients)
• Need for more help or
equipment
• Mechanism of injury

BTLS Primary Survey

Initial Assessment

• General impression
• Initial level of consciousness
• Manual stabilization of cervical
spine
• ABCs

Mechanism
of Injury

Rapid Trauma Survey Focused Exam

Load-and-
Go
Situations

Secondary Survey Ongoing Exam

BTLS Ongoing Exam

Change in condition
 Patient
 Interventions

Perform and record

 Critical: every 5 minutes
 Stable: every 15 minutes
 Each time patient moved
 With each intervention
 If condition worsen
BTLS Ongoing Exam

Subjective Changes
 “How do you feel?
Reassess Mental Status
 LOC, Pupils, GCS
Reassess ABCs
 Patency, Vital Signs, Color, Skin Condition, Temperature, JVD,
 Tracheal Deviation, Breath Sounds, Heart Tones
Reassess Abdomen
 Development of Tenderness, Distention, Rigidity
Check Each Identified Injury
 Change in Status, PMS
Check Interventions
 Patency, Position, Flow Rate, Security
Summary

 BTLS Patient Assessment

– Key to trauma care
– Not difficult, but time-critical
– Rapid, orderly, thorough

 Remain calm
– Optimum speed by organization and teamwork