chapter 10 assessment of the trauma patient. overall assessment scheme scene size-up initial...

CHAPTER 10

Assessment of the Trauma Patient

Overall Assessment SchemeScene Size-UpScene Size-Up

Initial AssessmentInitial Assessment

TraumaTrauma MedicalMedical

Physical ExamPhysical Exam

Vital Signs &Vital Signs &SAMPLE HistorySAMPLE History

SAMPLE HistorySAMPLE History

Physical ExamPhysical Exam& Vital Signs& Vital Signs

DetailedDetailedPhysical ExamPhysical Exam

OngoingOngoingAssessmentAssessment

HOSPHOSP

Assessing the Trauma Patient

Is there a significant mechanism of injury?

NoPerform a focused

assessment.

YesPerform a rapid

assessment.

Mechanism of InjuryMechanism of Injury

Significant Significant Mechanism Mechanism

of Injuryof Injury(Always reconsider or do a(Always reconsider or do adouble check – it is easy todouble check – it is easy to

miss things)miss things)

Significant Mechanism of Injury

Ejection from vehicle/vehicle with intrusion

Death in same passenger compartment

Fall of greater than 20 feet or 3 times the patient’s height

Rollover of vehicle

High-speed vehicle collision

Vehicle-pedestrian collision


Motorcycle crash

Unresponsive or altered mental status

Penetrating injury of head, chest, or abdomen


Falls greater than 10 ft.

Bicycle collision

Vehicle in medium-speed collision

Infantsand Children


Mechanism of Injury:Interior of Vehicle

Deformities to a vehicle’s interior may show where person struck the surface and reveal a mechanism of injury.

Bent Steering WheelBent Steering Wheel

Broken MirrorBroken Mirror

Distorted PedalsDistorted Pedals

Spider-Webbed WindshieldSpider-Webbed Windshield

Deformed DashboardDeformed Dashboard

Consideration of Mechanism of InjuryMechanism of injury often results in specific hidden injuries

Seat Belts

If buckled, may have produced injuries

If patient had seat belt on, it doesn't mean they do not have injuries

Should injury resulting from harness

Airbags

May not be effective without the seatbelt

Patient can hit wheel after deflation

Arm injury from holding the steering wheel wrong

Lift the deployed airbag and look at the steering wheel

“Lift and look” under the bag after the patient has been removed

Any visible deformation of the steering wheel should be regarded as an indicator of potentially serious internal injury, and appropriate action should be taken

Damage to car body

If Significant Mechanismof Injury

Reconsider mechanism of injury/priority of transport.

Assess mental status.

Continue spine stabilization.

Perform a rapid trauma assessment.

Rapid TraumaRapid TraumaAssessmentAssessment

Terminology

Rapid trauma assessment = a rapid assessment of the head, neck, chest, abdomen, pelvis, extremities, and posterior of the body to detect signs and symptoms of injury

Platinum ten minutes = optimum time at a scene with a patient who has serious injuries

Golden hour = time for time of injury and surgery at the hospital

Rapid Trauma Assessment

Perform rapid trauma assessment on patients with significant mechanism of injury to determine life threatening injuries. In the responsive patient, symptoms should be sought before and during the trauma assessment.

The rapid trauma assessment is important in order to:

1. Estimate the severity of injuries (life-threatening)

2. Make a CUPS status determination

3. Make transport decision, which is dependent upon CUPS determination

4. Consider ALS intercept

5. Consider platinum ten minutes and golden hour


The rapid trauma assessment should be interrupted to provide life saving interventions:

1. Airway

2. Breathing

3. Circulation

*** These always come 1st in this order***

***Life before limb***

Performing a Rapid Trauma Assessment

Continue spinal stabilization – somebody holds head

Consider ALS request

Reconsider transport decision (CUPS)

Assess mental status (AVPU)

As you inspect and palpate, look, and feel for DCAP-BTLS

Inspect and Palpate forDCAP-BTLS

====

DCAP

DeformitiesContusionsAbrasionsPunctures/Penetrations

====

BTLS

BurnsTendernessLacerationsSwelling

*** Symptoms of injury found by inspection or palpation during the patient assessment.***

DeformitiesDeformities

ContusionsContusions

AbrasionsAbrasions

Punctures/PenetrationsPunctures/Penetrations

BurnsBurns

TendernessTenderness

LacerationsLacerations

SwellingSwelling


Head

Neck

Chest

Abdomen

Pelvis

Extremities

Posterior

Head: DCAP-BTLS + CrepitationHead: DCAP-BTLS + Crepitation

Do not apply significant pressure to the head if fluid is found coming from ears, nose and mouth (cerebrospinal fluid)

Crepitation = the grating sound or feeling of broken bones rubbing together

Neck: DCAP-BTLS + Jugular VeinNeck: DCAP-BTLS + Jugular VeinDistention and CrepitationDistention and Crepitation

Jugular vein distention is the bulging of the neck veins

Look for stoma, tracheostomy and tracheal deviation

You can apply a cervical collar at this point (be sure to check the back of the neck first)

Chest: DCAP-BTLS + Crepitation andChest: DCAP-BTLS + Crepitation andBreath Sounds Breath Sounds (Presence, Absence and Equality)

Look for paradoxical motion (movement of part of the chest in the opposite direction from the rest of the chest

Listen to breath sounds at the apices, mid-clavicular line, bilaterally and at the bases, mid-axillary line bilaterally

Mid-clavicular Mid-axillary

Listen to both sides of the chest. Is air entry Listen to both sides of the chest. Is air entry present? Absent? Equal on both sides? present? Absent? Equal on both sides? Compare left side to right side.Compare left side to right side.

Abdomen: DCAP-BTLS + Firmness and Abdomen: DCAP-BTLS + Firmness and DistentionDistention

Divide the abdomen into four quadrants – right upper quadrant (RUQ), right lower quadrant (RLQ), left upper quadrant (LUQ), and left lower quadrant (LLQ)

Coleostomy/Ileostomy – surgical opening in the wall of the abdomen with a bag in place to collect excretions from the digestive system

Look also for softness and distention (appearing larger than normal)

Pelvis: DCAP-BTLS (Pelvis: DCAP-BTLS (Compress gently.)

If no pain is noted, gently compress the pelvis to determine tenderness or motion (press in and down on pelvic wings) – DO NOT ROCK AND ROLL

Priapism – persistent erection of the penis that can result from spinal cord injury or certain medical problems

Extremities: DCAP-BTLS + Distal Pulse,Extremities: DCAP-BTLS + Distal Pulse,Sensation, Motor Function, and CrepitationSensation, Motor Function, and Crepitation

Pulse – is it present

Sensation – can the patient feel you touching his/her extremities

Motor Function – can the patient move his/her extremities

Posterior: DCAP-BTLSPosterior: DCAP-BTLS

Roll patient with spinal precautions and assess posterior body, inspect and palpate, examining for injuries or signs of injury (check spine, sides of spine/body, posterior of extremities and buttocks for injuries

Assess baseline vital signs.

Obtain SAMPLE history.

Reconsider requesting ALS.

Reconsider transport decision.


TransportTransport

If No Significant Mechanismof Injury (i.e. cut finger)

Perform focused history and physical exam based on the component of the rapid assessment. Performing the focused history and physical examination permits:

Assessment and treatment of injuries not identified in the initial assessment (DCAP-BTLS for the injured area)

Reconsideration of mechanism of injury

Assess baseline vital signs

Assess SAMPLE history

Vital Signs

Respirations

Pulse

Skin color, temperature, condition

Pupils

Blood Pressure

SAMPLE History

S = Signs and symptoms

A = Allergies

M = Medications

P = Pertinent past history

L = Last oral intake

E = Events leading to injury or illness

Rules of Assessment

Explain to the patient what you are doing.

Expose areas before assessing.

Assume spinal injury.

Cervical CollarCervical CollarSizing andSizing andApplicationApplication

Cervical CollarsCervical Collars

STIFNECK TM Rigid Extrication Collar

Philadelphia Cervical Collar TM

STIFNECK STIFNECK TMTM Collar Collar – – Seated PatientSeated Patient

Stabilize head and neck manually.

Sizing a Cervical CollarSizing a Cervical Collar

Measure the patient’s neck.

Measure the collar.

1

2

Slide collar up toward patient’s chin.


Position front of collar under chin.


Wrap collar around back of neck.


Secure the collar.


Rearrange fingers to maintain support.


Kneel at patient’s head.

STIFNECK STIFNECK TMTM Collar Collar –– Supine Patient Supine Patient

Stabilize the head and neck.


Maintain stabilization.


Slide back of collar underpatient’s neck.



Secure collar.


Maintain manual stabilization.

chapter 10 assessment of the trauma patient. overall assessment scheme scene size-up initial...

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