Chapter 2 Assessment and Initial Management of the Trauma Patient

1. Chapter 2 Assessment and Initial Management of the Trauma Patient

2. Assessment and Initial Management of the Trauma Patient Courtesy of ITLS Ontario

3. Overview Steps of ITLS Patient Assessment • ITLS Primary Survey • ITLS Secondary Survey • ITLS Ongoing Exam Initial Assessment related to Rapid Trauma Survey or Focused Exam • Initial Assessment interruptions Critical conditions and critical interventions Patient Assessment -

4. ITLS Patient Assessment ITLS Primary Survey • Scene Size-up • Initial Assessment • Rapid Trauma Survey or Focused Exam ITLS Secondary Survey ITLS Ongoing Exam Patient Assessment -

5. ITLS Primary Survey ITLS Primary Survey • Scene Size-up • Initial Assessment • Rapid Trauma Survey or Focused Exam Patient Assessment -

6. Scene Size-up Patient Assessment -

7. Scene Size-up Patient Assessment -

8. Initial Assessment Patient Assessment -

9. ITLS 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 Patient Assessment -

10. ITLS 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 Patient Assessment -

11. ITLS 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. Patient Assessment -

12. ITLS Primary Survey Initial Level of Consciousness • Cervical-spine stabilization Alert Responds to Verbalstimuli Responds to Pain Unresponsive Patient Assessment -

13. ITLS Primary Survey Airway: look, listen, feel • Direct: simple positioning and suctioning If not adequate, not quickly correctable • Interrupt: advanced airway techniques Patient Assessment -

14. ITLS Primary Survey Breathing: look, listen, feel • Direct: high-flow oxygen If not adequate • Direct: assisted ventilation Patient Assessment -

15. Breathing Rates Patient Assessment -

16. ITLS 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 Patient Assessment -

17. MOI Decision Dangerous generalized or unconscious • Rapid Trauma Survey Dangerous focused • Focused Exam Not significantInitial Assessment normal • Focused Exam Patient Assessment -

18. Priority Patient Dangerous MOI History • Loss of consciousness • Difficulty breathing • Severe pain in head, neck, torso High-risk group • Altered mental status • Difficulty breathing • Abnormal perfusion • Abnormal Initial Assessment Patient Assessment -

19. Rapid Trauma Survey Patient Assessment -

20. Rapid Trauma Survey Inspect Head and Neck Major Facial Injuries, Bruising, Swelling, Penetrations, Subcutaneous Emphysema Neck Vein Distention? Tracheal Deviation? Patient Assessment -

21. Rapid Trauma Survey Inspect Chest Asymmetry, Contusion, Penetrations, Paradoxical Motion, Instability, Crepitation Breath Sounds Present? Equal? (If unequal: Percussion) Heart Tones Patient Assessment -

22. Rapid Trauma Survey Abdomen Bruising, Penetration/Evisceration, Tenderness, Rigidity, Distention Pelvis Tenderness, Instability, Crepitation Patient Assessment -

23. Rapid Trauma Survey Lower/Upper Extremities Swelling, Deformity, Instability, Motor, Sensory Place Patient on Backboard Posterior Penetrations, Deformity, Presacral Edema Patient Assessment -

24. Rapid Trauma Survey If critical situation,transfer to ambulance to complete exam. Patient Assessment -

25. 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 Patient Assessment -

26. Glasgow Coma Scale *Decorticate posturing to pain **Decerebrate posturing to pain Patient Assessment -

27. Brief Targeted History S Symptoms A Allergies MMedications PPast medical history LLast oral intake E Events preceding incident Patient Assessment -

28. Load-and-Go Situations Initial Assessment • Altered mental status • Abnormal respiration • Abnormal circulation Shock potential • Abnormal chest exam • Tender, distended abdomen • Pelvic instability • Bilateral femur fractures Significant MOIand/orpoor general health Patient Assessment -

29. When in doubt—transport early! Patient Assessment -

30. Critical Interventions • Manage airway • Assist ventilation • Administer oxygen • Begin CPR • Control major external bleeding • On-scene procedures • Seal sucking chest • Stabilize flail chest • Decompress tension pneumothorax • Stabilize impaled • Complete packaging Patient Assessment -

31. 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 Patient Assessment -

32. ITLS Secondary Survey Patient Assessment -

33. ITLS 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 Patient Assessment -

34. ITLS Secondary Survey Initial Assessment • Repeat routinely Vital signs • Repeat routinely • Monitoring Detailed Exam • Head-to-toe • DCAP-BTLS Patient Assessment -

35. ITLS Secondary Survey Initial Assessment LOC AVPU Airway Control Cervical Spine Snoring, Gurgling, Stridor, Silence Breathing Present? Rate, Depth, Effort Carotid/Radial Pulses Present? Rate, Rhythm, Quality Skin Color, Temperature, Moisture; Capillary Refill Uncontrolled External Hemorrhage? Patient Assessment -

36. Detailed Exam: DCAP-BTLS Deformities Contusions Abrasions Penetrations Burns Tenderness Lacerations Swelling Patient Assessment -

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

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

39. ITLS Secondary Survey Abdomen DCAP-BTLS; Rigidity, Distention Pelvis DCAP-BTLS Lower/Upper Extremities DCAP-BTLS; TIC; PMS Posterior Examine only if not done in ITLS Primary Survey DCAP-BTLS Patient Assessment -

40. ITLS 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 worsens Patient Assessment -

41. ITLS 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 Patient Assessment -

42. Summary ITLS Patient Assessment • Key to trauma care • Not difficult, but time-critical • Rapid, orderly, thorough Remain calm • Optimum speed by organization and teamwork Patient Assessment -

43. Discussion Patient Assessment -