chapter 10 assessment of the trauma patient. overall assessment scheme scene size-up initial...
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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
Significant Mechanism of Injury
Motorcycle crash
Unresponsive or altered mental status
Penetrating injury of head, chest, or abdomen
Significant Mechanism of Injury
Falls greater than 10 ft.
Bicycle collision
Vehicle in medium-speed collision
Infantsand Children
Significant Mechanism of Injury
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
Rapid Trauma Assessment
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
Rapid Trauma Assessment
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.
Significant Mechanism of Injury
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.
STIFNECK STIFNECK TMTM Collar Collar – – Seated PatientSeated Patient
Position front of collar under chin.
STIFNECK STIFNECK TMTM Collar Collar – – Seated PatientSeated Patient
Wrap collar around back of neck.
STIFNECK STIFNECK TMTM Collar Collar – – Seated PatientSeated Patient
Secure the collar.
STIFNECK STIFNECK TMTM Collar Collar – – Seated PatientSeated Patient
Rearrange fingers to maintain support.
STIFNECK STIFNECK TMTM Collar Collar – – Seated PatientSeated Patient
Kneel at patient’s head.
STIFNECK STIFNECK TMTM Collar Collar –– Supine Patient Supine Patient
Stabilize the head and neck.
STIFNECK STIFNECK TMTM Collar Collar –– Supine Patient Supine Patient
Maintain stabilization.
STIFNECK STIFNECK TMTM Collar Collar –– Supine Patient Supine Patient
Slide back of collar underpatient’s neck.
STIFNECK STIFNECK TMTM Collar Collar –– Supine Patient Supine Patient
STIFNECK STIFNECK TMTM Collar Collar –– Supine Patient Supine Patient
Secure collar.
STIFNECK STIFNECK TMTM Collar Collar –– Supine Patient Supine Patient
Maintain manual stabilization.