Assessment And Initial Management
- 1. Assessment and Initial Management of the Trauma Patient
- 2. INTRODUCTIO N Rapid systematic assessment is the key Interventions identified as lifesaving measures are initiated immediately A-B-C’s - first step in initial assessment
- 3. SCENE SIZE-UP COURTESY OF BONNIE MENEELY, R.N.
- 4. SCENE SAFETY/ SECURITY Medic situational assessment differs from civilian scene size-up. Centers around an awareness of the tactical situation and current hostilities. Examine Battlefield: Determine zones of fire Routes of access and egress Casualties occur over time changing demands
- 5. CARE UNDER FIRE What care can be offered at casualty’s side Effects of movement, noise, and light Movement to safety Cover and Concealment
- 6. ENTERING A FIRE ZONE Seek cover and concealment Survey for small arms fire Detect for fire or explosives Determine NBC status Survey structures for stability
- 7. MOVING CASUALTY TO SAFE AREA FOR TREATMENT Low profile for casualty and yourself May need to request assistance Protection outweighs risk of aggravating injuries NEVER hesitate to move a casualty who is under fire. If casualty is not under fire, you may elect to delay movement if C-spine injury likely.
- 8. MECHANISM OF INJURY Determine how injury occurred Burns Ballistics Falls NBC Blast
- 9. NUMBER OF PATIENTS Consider Mass casualty situation Triage patients accordingly Need for assistance or additional supplies Manage time, equipment, and resources
- 10. ADDITIONAL HELP Direct self-aid/buddy aid Request of suppressive fire for movement of casualties Plan evacuation routes
- 11. C-SPINE STABILIZATION/ OTHER EQUIPMENT Spineboard C-collar Factors or Limitations of NBC environment Other equipment: Airway adjuncts Oxygen Extrication devices
- 12. ASSESSMENT AND INITIAL MANAGEMENT OF THE TRAUMA PATIENT
- 13. BTLS PRIMARY SURVEY Scene Size-up Initial Assessment Rapid Trauma Survey or Focused Exam
- 14. PURPOSES OF INITIAL ASSESSMENT Prioritize casualties Determine immediate life threatening conditions Information gathered used to make decisions concerning critical interventions and time of transport No secondary interventions implemented before completion of initial assessment
- 15. NO SECONDARY INTERVENTIONS WILL BE IMPLEMENTED BEFORE COMPLETION OF INITIAL ASSESSMENT EXCEPT FOR: Airway Obstruction Cardiac Arrest
- 16. FORM GENERAL IMPRESSION Observe position of casualty posture accessibility Appearance of casualty Begin to establish priorities of care
- 17. ESTABLISH C-SPINE CONTROL AT THIS TIME
- 18. LEVELS OF CONSCIOUSNESS A – A LERT AND ORIENTED V – RESPONDS TO V ERBAL STIMULI P – RESPONDS TO P AIN U – U NRESPONSIVE (NO COUGH OR GAG REFLEX)
- 19. ASSESS AIRWAY If patient is unable to speak or is unconscious then evaluate further
- 20. OPENING THE AIRWAY Modified Jaw Thrust
- 21. OBSTRUCTED AIRWAY Attempt to ventilate; if unsuccessful Reposition and attempt to ventilate again Visualize observing for obvious obstruction Suction, if needed
- 22. OBSTRUCTED AIRWAY con’t Consider FBAO management Consider Combi-tube Consider Needle Cricothroidotomy
- 23. RATE AND QUALITY OF RESPIRATIONS Absent - Ventilate twice and check pulse and do CPR if required. Then provide PPV at 12-15 resp/min with 15L/m of O2 Rate<12/min - BVM at 12-15/min with 15L/m of O2 Low Tidal Volume - BVM at 12-15/min with 15L/m of O2
- 24. RATE AND QUALITY OF RESPIRATIONS Labored - Oxygen by non-rebreather at 15L/min Normal or Rapid - All trauma patients should receive oxygen Ventilation rate is 12-15/min instead of 10-12 IAW AHA due to the patient being without oxygen for a probable extended period of time. The increase in ventilation rate also allows for mask leak which can average up to 40%.
- 25. ACTIONS FOR SPECIFIC AIRWAY SOUNDS Snoring - Jaw Thrust Gurgling - Suction Stridor – consider Combi-tube Silence - Follow steps in assessing airway
- 27. Assess Circulation Palpate carotid and radial pulses; brachial in an infant Check CCT Check for major bleeding
- 28. RADIAL PULSE Present - Note rate and quality Bradycardia - Consider spinal shock; head injury Tachycardia - Consider shock Absent - Check carotid pulse; note late shock (consider PASG)
- 29. CAROTID PULSE Present - Note rate and quality Bradycardia (<60bpm) - Consider spinal shock; head injury Tachycardia (>120bpm) - Consider shock Absent - CPR + BVM+O2, Defib with AED as appropriate
- 30. CHECK FOR MAJOR BLEEDING Direct pressure and elevation Pressure dressing Pressure points Tourniquet PASG
- 31. CPR Combat situation CPR will be METT-T dependent If METT-T allows, you would begin CPR for the potentially expectant patient
- 32. EXPOSE WOUNDS Remove all equipment and clothing from area around wounds Identify any additional life-threatening injuries
- 33. DCAP-BLS Deformities Contusions Abrasions Penetrations Burns Lacerations Swelling
- 34. Deformities
- 36. Abrasions
- 38. Burns
- 39. Lacerations
- 40. Swelling
- 41. PALPATION Touching or feeling for: TIC TRD-P
- 42. TIC Acronym used when palpating body parts of the body TIC Tenderness Instability Crepitus
- 43. TRD-P Acronym used when palpating the abdomen TRD-P Tenderness Rigidity Distention Pulsating Masses
- 44. RAPID TRAUMA SURVEY Quick “Head-To-Toe” Exam Head Neck Chest Abdomen Pelvis Extremities Back
- 45. RAPID TRAUMA SURVEY BRIEF exam done to find all life-threats No splinting done except for anatomically splinting casualty to a spineboard Only a few interventions are done on scene
- 46. INTERVENTIONS PERFORMED AT SCENE Initial Airway Management Assist Ventilations Begin CPR if METT-T allows Control of major external bleeding
- 47. INTERVENTIONS PERFORMED AT SCENE Seal sucking chest wounds Stabilize flail chest Decompress tension pneumothorax Stabilize impaled objects
- 48. HEAD DCAP-BLS Obvious hemorrhage Major facial injuries - consider other airway adjuncts TIC
- 49. NECK DCAP-BLS Retraction at suprasternal notch Tracheal deviation Jugular Vein Distention Use of accessory muscles TIC Cervical spine step-off
- 50. AUSCULTATE FOR AIR SOUNDS IN TRACHEA Stridor Gurgling Snoring
- 51. APPLY C-COLLAR AFTER ASSESSING NECK
- 52. Chest: DCAP-BLS + TIC, paradoxical motion, Symmetry, Breath Sounds (Presence and Quality) , and heart sounds (baseline measurement)
- 53. Listen to both sides of the chest. Is air entry present? Absent? Equal on both sides? Compare left side to right side. Mid-Clavicular Mid-Axillary
- 54. DIMINISHED OR ABSENT BREATH SOUNDS Percuss to check for hemothorax vs. pneumothorax Hypo-resonance = Hemothorax Hyper-resonance = Pneumothorax
- 55. PNEUMOTHORAX OR COLLAPSED LUNG Collection of air or gas in pleural spaces Open chest wounds that permit entrance of air May occur spontaneously without apparent cause
- 57. TENSION PNEUMOTHORAX Required as consideration by any or all of the following Decreased or absent breath sounds Decreasing LOC Absent radial pulse Cyanosis Jugular Vein Distention Tracheal Deviation Decreasing bag compliance
- 59. INDICATIONS TO DECOMPRESS TENSION PNEUMOTHORAX The presence of tension pneumothorax with decompensation as evidenced by more than one of the following: Respiratory distress and cyanosis Loss of radial pulse (late shock) Decreasing LOC
- 60. ABDOMEN DCAP - BLS External blood loss Impaled objects Evisceration Inspect posterior abdomen for exit wounds/bruising Palpate for: TRD-P
- 61. PELVIS DCAP-BLS Priaprism Incontinence TIC Symphysis Pubis Iliac Crests
- 62. EXTREMITIES Examine lower then upper extremities DCAP-BLS TIC PMS in each extremity
- 63. LOGROLL AND PLACE ON BACKBOARD UNLESS CONTRAINDICATED CONTRAINDICATIONS TO LOGROLL: Pelvic Instability Bilateral Femur Fractures A Scoop Litter is required with these injuries
- 64. BACK Done DURING transfer to backboard DCAP - BLS Rectal Bleeding TIC
- 65. SAMPLE HISTORY S – SIGNS/ S YMPTOMS A – A LLERGIES M – M EDICATIONS P – P AST MEDICAL HISTORY L – L AST MEAL E – E VENTS PRIOR TO INJURY
- 66. OBTAIN BASELINE VITALS Pulse Respirations Blood Pressure Pupils CCT
- 67. Neurological Exam Perform brief exam if patient has an altered mental status PERL Glasgow Coma Scale (GCS) Assess disability
- 68. TRANSPORT PATIENT OR MOVE PATIENT TO CASUALTY COLLECTION POINT