Initial Assessment and Management of Trauma Temple College EMS Professions
Introduction • Trauma • Leading killer from ages 1 to 44 • Up to one-third of deaths are preventable
Introduction • Golden Hour • Time to reach operating room • NOT time for transport • NOT time in Emergency Department
Introduction • EMS does NOT have a Golden Hour • EMS has a Platinum Ten Minutes
Introduction • Patients in Golden Hour must be: • Recognized quickly • Transported to APPROPRIATE facility
Introduction • Survival depends on assessment skills • Good assessment results from • An organized approach • Clearly defined priorities
Size-Up • Safety • Scene • How does scene look? • How many patients? • Where are they? • Situation • Additional resources? • Critical vs non-critical patient?
Initial Assessment (Primary Survey) • Find life threats • If life threat present, CORRECT IT! • If life threat can’t be corrected • Support ABCs • TRANSPORT!!
Primary Survey With critical trauma you may never get beyond primary survey
Airway with C-Spine Control • You don’t need a C-collar yet • Return head to neutral position • Stabilize without traction
Airway with C-Spine Control • Noisy breathing is obstructed breathing • But all obstructed breathing is not noisy
Airway with C-Spine Control • Anticipate airway problems with • Decreased level of consciousness • Head trauma • Facial trauma • Neck trauma • Upper chest trauma • Open, Clear, Maintain
Breathing • Is air moving? • Is it moving adequately? • Is oxygen getting to the blood?
Breathing • Look • Listen • Feel
Breathing • Oxygenate immediately if: • Decreased level of consciousness • ? Shock • ? Severe hemorrhage • Chest pain • Chest trauma • Dyspnea • Respiratory distress
Breathing If you think about giving oxygen, GIVE IT!!
Breathing • Consider assisting ventilations if: • Respirations <12 • Respirations >24 • Tidal volume decreased • Respiratory effort increased
Breathing If you can’t tell if ventilations are adequate, they aren’t!! If you are wondering whether or not to bag the patient, you should!!
Breathing • If respirations compromised: • Expose chest • Inspect front and back • Palpate front and back • Auscultate front and back
Circulation • Is heart beating? • Is there serious external bleeding? • Is the patient perfusing?
Circulation • Does patient have radial pulse? • Absent radial = systolic BP < 80 • Does patient have carotid pulse? • Absent carotid = systolic BP < 60
Circulation • No carotid pulse? • Extricate • CPR • Pneumatic Antishock Garment • Run!!!! • Survival rate from cardiac arrest secondary to blunt trauma is < 1%
Circulation • Serious external bleeding? • Direct pressure (hand, bandage, PASG) • Tourniquet as last resort • All bleeding stops eventually!
Circulation • Is patient in shock? • Cool, pale, moist skin = shock, until proven otherwise • Capillary refill > 2 sec = shock until proven otherwise • Restlessness, anxiety, combativeness = shock until proven otherwise
Circulation • If possible internal hemorrhage, QUICKLY expose, palpate: • Abdomen • Pelvis • Thighs
Disability (CNS Function) • Level of Consciousness = Best brain perfusion indicator • Use AVPU initially • Check pupils • The eyes are the window of the CNS
Disability (CNS Function) Decreased LOC in trauma = Head injury until proven otherwise
Expose and Examine • You can’t treat what you don’t find! • If you don’t look, you won’t see! • Remove ALL clothing from critical patients ASAP • Avoid delaying resuscitation while disrobing patient • Cover patient with blanket when finished
The “Load and Go” Situations • Head injury with decreased LOC • Airway obstruction unrelieved by mechanical methods • Conditions resulting in inadequate breathing • Shock • Conditions that rapidly lead to shock • Tender, distended abdomen • Pelvic instability • Bilateral femur fractures • Traumatic cardiopulmonary arrest
Initial Assessment A blood pressure or an exact respiratory or pulse rate is NOT necessary to tell that your patient is critical !!!!!
Initial Assessment If the patient looks sick, he’s sick!!!
Initial Resuscitation • Treat as you go! • Aggressively correct hypoxia and inadequate ventilation. • Control external blood loss.
Initial Resuscitation • Immobilize C-spine (rigid collar) • Keep airway open • Oxygenate • Rapidly extricate to long board • Begin assisted ventilation with BVM • Expose • Apply and inflate PASG • Transport • Reassess and report in route • Consider requesting ALS intercept
Initial Resuscitation Minimum Time On Scene Maximum Treatment In Route
Detailed Exam (Secondary Survey) • History and Physical Exam • You WILL get here with MOST trauma patients • Perform ONLY after initial assessment is completed and life threats corrected • Do NOT hold critical patients in field for detailed exam
Physical Exam • Stepwise, organized • Every patient, same way, every time • Superior to inferior; proximal to distal • Look--Listen--Feel
History • Chief complaint • What PATIENT says problem is • Not necessarily what you see
History • A = Allergies • M = Medications • P = Past medical history • L = Last oral intake • E = Events leading up to incident
Definitive Field Care Performed ONLY on stable patients
Definitive Field Care • Stable patients can receive attention for individual injuries before transport • Bandaging • Splinting • Reassess carefully for hidden problems • If patient becomes unstable at any time,TRANSPORT
Reevaluation • Ventilation and perfusion status • Repeat vital signs • Continued stabilization of identified problems • Continued reassessment for unidentified problems
PowerPoint Source • Slides for this presentation from Temple College EMS: http://www.templejc.edu/dept/ems/pages/powerpoint.html