PATIENT ASSESSMENT

TRAUMA

OBJECTIVES
As a Medic, you should be able to:

Establish priorities of care based on lifethreatening conditions. Distinguish between patient assessment and patient management. Explain the purpose of the primary and secondary survey. Detail in the correct order the assessment of each component of the primary survey.

OBJECTIVES
As a Medic, you should be able to:

Identify potentially life-threatening conditions that can be discovered in the primary survey. Discuss patient management techniques that may be used if abnormalities are found in the primary survey. Differentiate between resuscitation procedures for medical patients and trauma patients.

OBJECTIVES
As a Medic, you should be able to:

Describe the examination techniques for inspection, palpation, and auscultation. Explain in detail the physical examination for each component of the secondary survey. Apply effective patient-interviewing techniques to given scenarios. Describe the essential elements of the patient history

OBJECTIVES
As a Medic, you should be able to:

Describe the process of patient reevaluation. Describe special considerations in assessing pediatric, geriatric, disabled, and nonEnglish-speaking patients.

BODY SUBSTANCE ISOLATION

Personal protective equipment (PPE) must be applied prior to contact with any body substance, common PPE available to the medic should include the following: Gloves. Eye protection. Respiratory protection (Surgical Mask) Impervious clothing.

INITIAL SCENE ASSESSMENT/SAFETY

Ask yourself if the scene is safe and adequate protection is provided to the following: Yourself(the rescuers). The Patient(s). The Bystanders. If the scene is not safe, take the appropriate actions to secure the scene prior to moving forward to the incident site.

INITIAL SCENE ASSESSMENT

These actions may include but are not limited to the following: Tactical situation - provide tactical security in the military environment and police security in the civil environment. Fire - allow fire personnel to suppress the fire. Electrical hazard - allow power company to cut power. Special Rescue, i.e.., hazmat, high angle, swift water.

DETERMINE THE MECHANISM OF INJURY

Look at the environment and ask yourself what caused the injury? Examples: Gun shot wound (GSW)/stab wound. Assault. Blast injury. Fall from heights. Motor vehicle accident (MVA)/Motorcycle accident (MCA).

DETERMINE THE NUMBER OF PATIENTS

How many patients: Consider triage if two or more. Triage is initiated by the senior medical provider at the scene. He rapidly surveys each casualty and places them in a triage category.

DETERMINE THE NUMBER OF PATIENTS

MILITARY TRIAGE Immediate Delayed Minimal Expectant

DETERMINE THE NUMBER OF PATIENTS

CIVILIAN TRIAGE Critical/Immediate Delayed Mild Dead/Non-salvageable

REQUEST ADDITIONAL HELP

Ask yourself if you need to call for additional help - medical or technical, i.e.., additional medics, air medevac, police, fire, special rescue.

DIRECTS C-SPINE STABILIZATION

Spinal stabilization will be used on all trauma patients if the MOI indicates, i.e., Fall from heights, MVA/MCA, etc.
NOTE: Spinal stabilization will be used in almost all classroom scenarios. Real life scenarios will be dictated by MOI, local protocols, and environment.

Note:
Spinal stabilization can be directed by the primary care provider if there is more than one provider - USE YOUR ASSETS. The C-Collar is not placed on the patient at this time - it is placed on the patient after the neck is assessed in the rapid trauma assessment.

INITIAL PATIENT CONTACT

Identify yourself and establish the ProviderPatient relationship. Example: Hey buddy Im a Medic and Im here to help you.

GENERAL IMPRESSION
The general impression is your immediate assessment formed in the first few seconds of exposure to the patients environment combined with the chief complaint. What is the MOI and does the patient have any life threatening injuries? (This is not verbalized to the patient but will be verbalized for classroom scenarios).

DETERMINE RESPONSIVENESS/LOC

A - Alert, responds without prompting. V - Verbal stimulus, responds to verbal commands (not necessarily appropriately) P - Painful stimulus, withdraws or groans when pain is elicited (sternal rub/nail bed). U - Unresponsive, does not respond to verbal or painful stimuli.

DETERMINE LIFE THREATS

Identify injuries that may compromise the airway/breathing (open chest wound) or produce profound irreversible shock (massive external hemorrhage). Manage rapidly and temporarily at this time.

POSITION THE PATIENT

If the patient is found in any other position other than supine, you may have to reposition to provide appropriate care. If required this must be done with spinal immobilization. If appropriate care can be given with the patient in the position found, defer movement until it interferes with treatment.

ASSESS AIRWAY AND BREATHING

If the patient is alert and oriented - move to assess the patients breathing. If the patient has an altered LOC consider the following: NOTE: THIS MUST BE ACCOMPLISHED WITHIN 5 MINUTES OF STARTING THE ASSESSMENT

OPEN THE AIRWAY

MODIFIED JAW THRUST: For Trauma and suspected C-Spine injury. HEAD-TILT, CHIN-LIFT: For Medical.
Clear Airway as required: (suction/Heimlich/laryngoscopic)

ASSESS AIRWAY

LOOK - I see bilateral rise and fall of the chest. LISTEN - I hear deep and normal respiratory effort. FEEL - I feel exhalation on my ear. NOTE: The rate is not counted, but continuous practice and experience allows you to guestimate the rate.

INSERT APPROPRIATE AIRWAY ADJUNCT

ORO/NASOPHARYNGEAL ORO/NASOTREACHEAL SURGICAL AIRWAY

REASSESS AIRWAY

LOOK - I see bilateral rise and fall of the chest. LISTEN - I hear deep and normal respiratory effort. FEEL - I feel exhalation on my ear. At this time it appears I have adequate placement of my airway adjunct.

ASSESS BREATHING

APPROXIMATE RATE: Use the method of abnormal vs. normal rate. (<10 or >28). Slow or Rapid. RHYTHM: Regular vs. Irregular. DEPTH: Shallow vs. Deep.

ASSURES ADEQUATE VENTILATION

Non-Rebreather face mask: Normal rate and depth. Bag Valve Mask with Reservoir: For abnormal or inadequate respirations.

ADMINISTER 100% OXYGEN

ALL TRAUMA PATIENTS RECEIVE HIGH CONCENTRATION OXYGEN. IT IS ESSENTIAL TO INCREASE THE OXYGEN CARRYING CAPABILITY OF THE BLOOD TO PREVENT BRAIN DAMAGE AND ORGAN FAILURE DUE TO HYPOXIA IN THE HEMODYNAMICALLY CHALLENGED PATIENT.

EXPOSE THE CHEST

Proper assessment of airway interventions and inspection for life threatening injuries requires exposure of the thorax

INSPECT ANTERIOR CHEST

Inspect the anterior thorax for obvious lifethreatening injuries. (i.e. Sucking Chest Wound) Manage injuries that are immediately life threatening or compromise breathing.

AUSCULTATE ANTERIOR CHEST

The patients lung fields should be auscultated at the apices X 1 bilateral for the presence of breath sounds. Decreased or absent breath sounds may indicate tension pneumothorax. assess placement of ET tube and BVM if assisting ventilations.

PALPATE ANTERIOR CHEST

Palpate the anterior chest for obvious rib fractures or flail segments that may produce a difficulty for the patient to breath.

PALPATE POSTERIOR CHEST (RAKE)

Palpate the posterior thorax by using a raking technique in an attempt to feel any penetrating or exit wounds. Use caution to prevent unnecessary spinal manipulation. Continuously look at your gloves for signs of blood.

TREATMENTS

TREAT ALL INJURIES THAT CAN OR WILL CREATE COMPLICATIONS WITH AIRWAY OR BREATHING. PATIENTS THAT ARE NOT BREATHING OR BREATHING INADEQUATELY DETERIORATE RAPIDLY.

ASSESS CIRCULATION

CAROTID PULSE: BP is > 60. FEMORAL PULSE: BP is > 70. RADIAL PULSE: BP is > 80.

ASSESS PULSE

If the patient is alert - assess the radial pulse. If the patient has a decreased LOC - assess both the carotid and radial pulses simultaneously. If no pulse - begin CPR.

ASSESS PERFUSION
Assessment of perfusion can be easily accomplished in three ways: Capillary refill - < 2 seconds Skin color - In light skinned patients color will be obvious, in dark skinned patients it is easiest to assess the mucous membranes of mouth or fingernail beds. Skin temperature - Warm.

IDENTIFY AND CONTROL MAJOR BLEEDING

Assess the patient for major bleeding, perform a blood sweep from the patients head to their toes, if you need to expose the patient, do so to manage life-threatening bleeding. NOTE: If life-threatening bleeding is detected it will be managed immediately.

IDENTIFY PRIORITY PATIENTS & MAKE TRANSPORT DECISION

Priority patients include: Poor General Impression. Unresponsive with no gag reflex. Respiratory Difficulty. Chest Pain or BP less than 100 systolic. Uncontrolled Bleeding.

FOCUSED HISTORY AND PHYSICAL EXAM OR RAPID TRAUMA ASSESSMENT

NON LIFE-THREATENING INJURIES AND MEDICAL PATIENTS: Focused history and physical exam. LIFE-THREATENING OR MOI CONSIDERED TO BE HIGH RISK: Rapid Trauma Assessment.

EXPOSE

Complete exposure of the patient is required to perform an adequate rapid trauma assessment and detailed physical exam. NOTE: Some injuries, such as pelvis or femur fractures can cause massive internal hemorrhage. They can also be easily missed due to the lack of external bleeding.

DOC, IT HURTS, RIGHT BY MY...

EXPOSE, EXPOSE! YOU CANT TREAT WHAT YOU CANT SEE!

REASSESS

AIRWAY BREATHING CIRCULATION PREVIOUS TREATMENTS/INTERVENTIONS

ASSESS THE HEAD

Obvious head injuries. Maxillofacial injuries that can compromise the airway. Severe bleeding. Cerebral Spinal Fluid from nose or ears.

ASSESS THE NECK

Obvious injuries. (Treat all injuries to the neck at this point as rapidly as possible). Jugular Vein Distention (JVD). Tracheal Deviation. Medical Alert Tags. Palpate C-Spine for deformities.

APPLY C-COLLAR

Should be applied as soon as possible after inspection of neck. If not applied at this point, it must be applied prior to moving or rolling the patient.

ASSESS THE CHEST

Obvious injuries: Contusions and abrasions over the chest wall. Penetrating wounds (Sucking Chest Wound). Paradoxical motion. Palpate for crepitus and flail segments.

ASSESS THE ABDOMEN

Inspect for obvious injuries: Evicerations Penetrating wounds and wounds that may enter the chest cavity.

ASSESS THE PELVIS

Stable or Unstable. Consider MAST at this point for stabilization of a fractured pelvis but do not apply at this time. Application of MAST is recommended prior to moving the patient.

Inspect Palpate NOTE: At this time, all you will be concerned about is looking for major hemorrhage and long bone fractures. Reassess previous treatments and treat lifethreatening injuries. Consider alignment to assist with hemorrhage control

ASSESS THE LOWER EXTREMITIES

Inspect Palpate NOTE: At this time, all you will be concerned about is looking for major hemorrhage and long bone fractures. Reassess previous treatments and treat lifethreatening injuries. Consider alignment to assist with hemorrhage control

ASSESS THE UPPER EXTREMITIES

LOG ROLL
NOTE: THE C-COLLAR MUST BE APPLIED PRIOR TO ROLLING OR MOVING A PATIENT WITH A SUSPECTED C-SPINE INJURY. Maintain C-Spine and L-Spine control and in line. Consider MAST. Assess the posterior from head to foot.

OBTAIN A S.A.M.P.L.E. HISTORY

Signs and Symptoms. Allergies. Medications. Pertinent past medical history. Last oral intake(time or hours ago). Events leading up to the injury/illness. NOTE: It may be required to gain this information from bystanders at the scene or family members in better condition.

INITIATE TRANSPORTATION

The golden hour begins with injury to the patient not with the arrival of EMS. Trauma patients are not resuscitated in the field only in the E.D. or O.R. NOTE: TRANSPORTATION OF THE PATIENT MUST BE INITIATED WITHIN 10 MINUTES OF STARTING THE ASSESSMENT.

GAINS I.V. ACCESS

Two large bore (18ga. or larger) Catheters. Ringers Lactate or Normal Saline. NOTE: For test purposes a patent IV must be established in less than 3 attempts. The second IV will be moulaged or simulated. Reassess ABCs and treatments after each IV is initiated.

OBTAINS BASELINE VITALS*

Pulse- Rate, Strength, and Rhythm. Respirations- Rate, Depth, Rhythm. Blood Pressure- During transportation it may be difficult to auscultate the diastolic due to noise. BP by palpation may be substituted. Temperature- If heat injury or exposure to cold is suspected. *NOTE: You may direct assistant to obtain.

DETAILED PHYSICAL EXAM/ONGOING ASSESSMENT

HEAD TO TOE, TREAT AS YOU GO

REASSESS

Airway - ET tube. Breathing - Rate, rhythm, depth, BVM. Note: Dont forget to check you O2 tank! Circulation - Pulses/Cap refill. Treatments on serious injuries IVs (infiltration, still running, bags not empty).

ASSESS THE HEAD

Inspect and palpate the scalp DCAP-BTLS. Head- battle signs. Eyes- Coons eyes. Ears- Blood/CSF. Nose- Blood/CSF. Throat/Mouth- Airway obstructions and interventions. Treat all minor injuries.

ASSESS THE NECK

Inspect the neck (DO NOT REMOVE CCOLLAR). Reassess for JVD. Reassess for tracheal deviation. Injuries that were treated before the CCollar.

ASSESS THE SHOULDER GIRDLE

Assess in a similar fashion to checking for pelvis stability. Assess for fractured clavicles. NOTE: Fractures to the shoulder girdle carry a high suspicion of C-spine involvement/injury.

ASSESS THE CHEST

Inspect. Auscultate X3 bilaterally. Auscultate the heart (note rate, rhythm) Percuss X3 bilaterally. Palpate. Treat minor injuries/Reassess treatments.

ATTACH ECG
NOTE: If available. Interpret ECG - tachycardia, PEA/EMD. Myocardial Contusion - PVCs/PACs.

ASSESS THE ABDOMEN/PELVIS

Inspect the abdomen. Palpate all 4 quadrants for distention, masses, pain, tenderness, guarding. Assess the pelvis for stability. Treat minor injuries, Reassesses MAST/previous treatments. NOTE: DO NOT OVERMANIPULATE THE UNSTABLE PELVIS!

ASSESS THE GENITALIA/PERINEUM

Urination, Defication, and or bleeding. Priaprism.

ASSESSES THE LOWER EXTREMITIES

Inspect and palpate both legs. Assess motor, sensory, and circulatory function of both legs. Treat/splint minor injuries Reassess previous treatments/MAST.

ASSESS UPPER EXTREMITIES

Inspect and palpate both arms. Assess motor, sensory, and circulatory function of both arms. Treat/splint minor injuries Reassess previous treatments/IVs.

VERBALIZE ONGOING RE-ASSESSMENT

ABCs. (Dont forget your O2 tank) Vital signs/ECG. IVs. Treatments given. NOTE: This sequence should be done continuously or at a minimum of every 5 minutes.

THE END

The detailed physical exam, to include IVs will be completed in 12 minutes. The time for the IV itself will be 6 minutes.

T I O S E NS U Q ? ?

A fully trained 91W.