Chapter2 trauma assessment and management

Editor's Notes

• #2: Key Lecture Points The concept of simultaneous assessment (team leader) and delegated intervention (team members) in life-threatening emergencies needs to be stressed. Point out that the Initial Assessment is interrupted only for airway obstruction, when the scene becomes too dangerous, or the need to perform CPR. The step-by-step assessment scheme must be taught. Emphasize the need to get the critically injured patient out of the field and to an appropriate hospital as quickly as possible. The 10-minute rule must be reinforced. Stress that the Ongoing Exam should be repeated any time the patient's condition changes.
• #3: NOTE: Remember ITLS Primary Assessment and ITLS Secondary Assessment are taught in skill stations.
• #6: IMAGE: Figure 2-1: ITLS Patient Assessment. NOTE: Use flowchart miniature to conceptualize and demonstrate how parts of Assessment fit together. You begin in same place for all patients, decision takes you on different paths, but come back to same for all patients. (Students do not need to be able to read flowchart on screen.) NOTE: (U.S.) ITLS patient assessment (Primary Survey, Secondary Survey, and Ongoing Exam) is consistent with U.S. Department of Transportation guidelines. FLOWCHART: (Top box—STEP for all patients) ITLS Primary Survey starts with Scene Size-up. If scene is safe to enter, moves on to next STEP. (Second box—STEP for all patients) Initial Assessment is VERY BRIEF exam of level of consciousness and ABCs, moves to next STEP. (Top diamond—DECISION splits group) Mechanism of Injury DECISION and information obtained in first two steps, go one of two directions and perform either Rapid Trauma Survey or Focused Exam. (Left branch—STEP) Rapid Trauma Survey is RAPID head-to-toe exam to determine if immediately life-threatening conditions exist and to identify those patients who should have immediate transport. (Right branch—STEP) Focused Exam is limited to area of injury. (Both branches come back to center diamond for DECISION) Based on situation: DECISION to perform or not perform ITLS Secondary Survey step. DECISION to perform or not perform ITLS Ongoing Exam step. (Bottom left box—STEP) ITLS Secondary Survey in that Secondary Survey is an evaluation for all injuries, not just life-threatening ones. (Bottom right box—STEP) ITLS Ongoing Exam is meant to identify changes in patient's condition. ITLS Secondary Survey and ITLS Ongoing Exam steps can be performed as needed.
• #7: IMAGE: Figure 2-2 ITLS Primary Survey. The purpose of the Primary Survey is to determine if immediately life-threatening conditions exist and to identify those patients who should have immediate transport to the hospital.
• #8: Experience has shown that most mistakes occur because the team leader stops to perform an intervention and forgets to perform part of the assessment. Delegate interventions to your team members while you continue the assessment. This is an important concept that immediately addresses problems encountered and yet does not interrupt the assessment sequence and does not increase scene time. This is what teamwork is all about. Interventions performed based on patient needs, resources available and time it will take to execute. Performed by team members during assessment phases without causing interruptions of the assessment.
• #9: IMAGE: CALLOUT from ITLS Primary Survey. NOTE: Use miniature to conceptualize and demonstrate how survey is a series of steps to be done in sequence without deviation. (Students do not need to be able to read steps on screen.) NOTE: The next series of slides steps through Scene Size-up. Remember: this skill will be taught in skill stations. Don't over lecture. Scene Size-up is the first step of the Primary Survey.
• #10: NOTE: Scene Size-up has already been discussed; do not repeat details here. NOTE: Click on the screenshot in presentation mode to play the Video clip “ITLS7e Scene Survey” in a browser window. Close the browser window to return to the presentation. It cannot be stressed too much that failure to perform preliminary actions can jeopardize lives. Perform Scene Size-up as described in Chapter 1. If there are more patients than your team can effectively handle, triage them rapidly utilizing Triage Decision Tree and initiate MCI protocols. (See Chapter 1 and also Multicasualty Incidents and Triage under Additional Resources.) The Scene Size-up will set stage for how you will perform rest of ITLS Primary Survey.
• #11: IMAGE: CALLOUT from ITLS Primary Survey (Figure 2-4). NOTE: Use miniature to conceptualize and demonstrate how survey is a series of steps to be done in sequence without deviation. (Students do not need to be able to read steps on screen.) NOTE: The next series of slides steps through Initial Assessment. Remember: this skill will be taught in skill stations. Initial Assessment prioritizes and determines existence of immediately life-threatening conditions.
• #12: NOTE: Click on the screenshot in presentation mode to play the Video clip “ITLS7e Initial Assessment” in a browser window. Close the browser window to return to the presentation. Once scene is safe to enter, team leader must focus on rapid assessment. All decisions on treatment require that you have identified life-threatening conditions. If immediate interventions are needed, delegate them to your team members while you continue assessment. Experience has shown that most mistakes occur because team leader stops to perform an intervention and forgets to perform part of assessment. Team approach makes most efficient use of time and allows you to rapidly perform Initial Assessment without performing noninvasive airway interventions yourself, which can interrupt your thought process. Purpose of Initial Assessment is to prioritize and determine existence of immediately life-threatening conditions. Information gathered is used to make decisions about critical interventions and time of transport. Initial Assessment is made up of general impression upon approaching patient, an evaluation of level of consciousness (LOC), manual stabilization of cervical spine (if needed), and assessment of airway, breathing, and circulation (ABCs).
• #13: Initial Assessment and Rapid Trauma Survey combined should take less than 2 minutes. Remember, once you begin ITLS Primary Survey, only 4 things should cause you to interrupt completion of assessment: Scene becomes unsafe. Must treat an airway obstruction. Must treat cardiac arrest. Must treat life-threatening bleeding. All other problems (such as respiratory arrest or dyspnea) may be addressed by team members. Stopping during survey causes you to overlook essential items. For critical patients, goal should be to have on-scene times of 5 minutes or less. While interventions may be important, only thing proven to increase survival of trauma patients is decreasing time to definitive care (trauma center).
• #14: On approach, note patient's approximate age, sex, weight, and general appearance. Old and very young are at increased risk. Female patients may be pregnant. Observe position of patient. Body position and position in relation to surroundings. Note activity. (Is patient aware of surroundings, anxious, obviously in distress, etc.?) Any obvious major injuries or major bleeding? Observation of patient in relation to scene and mechanism of injury will help you prioritize. If there are multiple patients, rapidly triage them and begin evaluation of the most seriously injured patient first.
• #15: As team leader, try to approach patient from front (face to face, so patient does not turn head to see you). Assessment begins immediately, even if patient is being extricated. If there is a mechanism of injury that suggests spinal injury, immediately and gently but firmly stabilize head and neck in a neutral position (this can be delegated to a team member). Stabilize head and neck in position found. If head or neck is held in an angulated position and patient complains of pain on any attempt to straighten it. If patient is unconscious and neck is held to one side and does not move when you gently attempt to straighten it. Speak to patient and ask a question such as, “Can you tell me what happened?” Reply gives immediate information about both airway and level of consciousness. If responds appropriately to questioning, you can assume that airway is open and level of consciousness (LOC) is normal. If response is not appropriate, make a mental note of LOC using AVPU scale. Anything below “A” (alert) should trigger a systematic search for causes during Rapid Trauma Survey.
• #16: If patient cannot speak or is unconscious, further evaluation of airway should follow. Look, listen, and feel for movement of air. Position airway as needed. Avoid extending neck to open airway if trauma suspected. If airway obstructed (apnea, snoring, gurgling, stridor), use an appropriate method (reposition, sweep, suction) to open it immediately. Failure to quickly provide an open airway is one of three reasons to interrupt patient assessment part of ITLS Primary Survey. If simple positioning and suctioning fail to provide an adequate airway, or if stridor is present, advanced airway techniques may be necessary immediately.
• #18: Note rate and quality of pulses at wrist (brachial in infant). Checking pulse in neck is not necessary if awake and alert or has a palpable peripheral pulse. Quickly note whether rate is too slow or too fast, and note quality (thready, bounding, weak, irregular). Remember, pulse rate is checking to determine how well blood is circulating and if sufficient for good perfusion. Is it too fast for good perfusion? (>120 in an adult) Is it too slow for good perfusion? (<60 in an adult) It is not a determination of tachycardia or bradycardia. If pulse absent at neck, immediately start CPR (unless there is massive blunt trauma) and prepare for immediate transport. One of four reasons to interrupt assessment during ITLS Primary Survey. At wrist, note skin color, temperature, and condition (and capillary refill in an infant or small child). Pale, cool, clammy skin; thready radial pulse; and decreased LOC are best early assessments of decreased perfusion (shock). Direct control of bleeding.
• #19: If dangerous generalized mechanism of injury or if unconscious: Perform Initial Assessment and go directly to Rapid Trauma Survey. Perform interventions, transport, Ongoing Exams, and possibly a Secondary Survey en route. If dangerous focused mechanism of injury suggesting an isolated injury: Perform Initial Assessment and Focused Exam limited to area of injury. Full Rapid Trauma Survey is not required. Perform interventions, transport, Ongoing Exams, and possibly a Secondary Survey. If no significant life threat in mechanism of injury: Perform Initial Assessment and, if normal: Directly to a Focused Exam based on chief complaint. Secondary Survey would not be necessary.
• #20: IMAGE: CALLOUT from ITLS Primary Survey. NOTE: Use miniature to conceptualize and demonstrate how survey is a series of steps to be done in sequence without deviation. (Students do not need to be able to read steps on screen.) NOTE: The next series of slides steps through Rapid Trauma Survey. Remember: this skill will be taught in skill stations. Rapid Trauma Survey is a brief exam done to find all life-threats.
• #21: NOTE: Click on the screenshot in presentation mode to play the Video clip “ITLS7e Rapid Trauma Survey” in a browser window. Close the browser window to return to the presentation. NOTE: Remember: this skill will be taught in detail in skill stations. Inspect head and neck (look and feel). Major facial injuries, bruising, swelling, penetrations, subcutaneous emphysema. Neck vein distention? Tracheal deviation? Assessment of neck is a continuation of breathing and circulation by checking for JVD, tracheal deviation, and subcutaneous emphysema. A rigid cervical extrication collar may be applied at this time. Inspect chest—expose and look, feel, and listen. Asymmetry, contusion, penetrations, paradoxical motion, instability, crepitation. Note if ribs rise with respiration or if there is only diaphragmatic breathing. Look for signs of blunt trauma or open wounds. Feel for tenderness, instability, and crepitation (TIC). Breath sounds—listen. Present? Equal? Listen with stethoscope over lateral chest about fourth intercostal space in midaxillary line on both sides. If unequal: percussion. If breath sounds are not equal (decreased or absent on one side), percuss chest to determine whether patient is just splinting from pain or if a pneumothorax or a hemothorax is present. Heart tones: Very briefly notice heart sounds so you will have a baseline for changes such as development of muffled heart sounds. If abnormalities are found during chest exam (open chest wound, flail chest, tension pneumothorax, hemothorax), delegate appropriate intervention (seal open wound, stabilize flail, decompress severe tension pneumothorax). Abdomen: Expose and look: bruising, penetration/evisceration. Gently palpate: tenderness, rigidity, distention. Pelvis: Look for deformity or penetrating wounds. Feel for tenderness, instability, and crepitation by gently pressing down on symphysis and gently squeezing in on iliac crests. Note that tenderness is not same thing as being unstable. The pelvis may be tender and yet stable. If pelvis is unstable, you can feel pelvic ring collapse as you apply pressure. If pelvis is unstable, do not check again! Lower/upper extremities: Swelling, deformity, instability, motor, sensory. Assess both upper legs, looking for deformity and feeling for TIC. Remember that bilateral femur fractures can produce enough internal blood loss to be life-threatening. Scan for obvious wounds or deformities of arms and lower legs. Note whether patient can move fingers and toes before transferring to backboard. Place patient on backboard, if indicated by injuries. Transfer patient to a long backboard, checking posterior of patient as you do this. If patient has an unstable pelvis or bilateral femur fractures, to prevent further injuries, use a scoop stretcher (Figure 2-5) to transfer patient to a long backboard.
• #23: Baseline vital signs: Measured pulse, respirations, blood pressure. Obtain baseline vital signs and rest of SAMPLE history. Vital signs and SAMPLE should be done during transport for critical patients. Pupils: Size? Reactive? Equal? If altered mental status: Brief neurological exam Identify possible increased intracranial pressure (ICP). Includes pupils, Glasgow Coma Scale (GCS) score, and signs of cerebral herniation Always performed during transport Finger-stick glucose performed at beginning of transport Glasgow Coma Scale Score Eyes, voice, motor, orientation, emotional state Look for medical identification devices. Consider nontraumatic causes of altered mental status.
• #24: IMAGE: Table 2-4: Glasgow Coma Scale Score NOTE: Also referred to either as Glasgow Coma Scale or Glasgow Coma Score. Very important to do this as a baseline; how it changes is of critical importance. It is done at END of Rapid Trauma Survey (if altered mental status). It is done early in Secondary Survey.
• #25: NOTE: High-risk group (such as very young, very old, chronically ill) NOTE: Notice importance of breathing. Difficulty breathing appears in both groups. Load-and-go patients include: Dangerous mechanism of injury History that reveals: Loss of consciousness. Difficulty breathing. Severe pain of head, neck, or torso. High-risk group (such as very young, very old, chronically ill) Altered mental status Difficulty breathing Abnormal perfusion Any abnormality revealed during Initial Assessment
• #26: At same time as you are performing patient assessment part of ITLS Primary Survey, you or a team member obtain a brief target history (including SAMPLE history) from patient and from bystanders. A more detailed history may be taken later during ITLS Secondary Survey. Especially important: If information must be gathered from bystanders, since they will not be available to question once transport is initiated. If patient has loss of consciousness during transport.
• #27: NOTE: Significant mechanism of injury and/or poor general health has been added to “Load-and-Go” criteria. Upon completion of Initial Assessment and Rapid Trauma Survey or Focused Exam, enough information is available to decide if a critical situation is present. Patients with critical trauma situations are transported immediately. Most treatment interventions will be done during transport. If any of following critical injuries or conditions exist, transport immediately. Initial Assessment reveals: Altered mental status. Abnormal respiration. Abnormal circulation (shock or uncontrolled bleeding). Signs discovered during Rapid Trauma Survey of conditions that rapidly lead to shock Abnormal chest exam (flail chest, open wound, tension pneumothorax, hemothorax). Tender, distended abdomen. Pelvic instability. Bilateral femur fractures. Significant mechanism of injury and/or poor general health of patient As you consider mechanisms, age, general appearance, chronic illnesses, and so on, you may decide that patient is at higher risk than ITLS Primary Survey alone would suggest. These higher-risk patients should go to a trauma center even though they might not meet other criteria to go there. Remember that there are more considerations than just physical exam of patient.
• #28: NOTE: These will be discussed in other lectures. Do not spend time teaching techniques now. Emphasize that only procedures done on scene directly relate to components of ITLS Primary Survey. These “Fix Its” are done at scene, and most of them can be delegated to team members to perform while you continue ITLS Primary Survey. Patient may be in a state of compensated shock; anticipate needs.
• #29: NOTE: These will be discussed in other lectures. Do not spend time teaching techniques now. Emphasize that only procedures done on scene directly relate to components of ITLS Primary Survey. These “Fix Its” are done at scene, and most of them can be delegated to team members to perform while you continue ITLS Primary Survey. Patient may be in a state of compensated shock; anticipate needs.
• #30: Procedures that are not lifesaving, such as splinting, bandaging, insertion of IV lines, or even emergency endotracheal intubation, must not hold up transport of critical patient. If BVM ventilation is sufficient to transfer to ambulance and initiate transport, perform endotracheal intubation in transit. At this point, ITLS Primary Survey is over and team leader may help other rescuers with patient care. It is extremely important to contact medical direction as early as possible with critical patients. It takes time to get appropriate surgeon and operating room team in place, and critical patient has no time to wait. Always notify receiving facility of your estimated time of arrival (ETA), condition of patient, and any special needs on arrival. 
• #31: IMAGE: Figure 2-1 ITLS Patient Assessment. Ongoing assessment and management include critical procedures performed on scene and during transport and communication with medical direction. Ongoing Exam is abbreviated exam to assess for changes in condition. Concentrate on reassessing only those things that may change. In contrast to ITLS Secondary Survey, which is performed only once, Ongoing Exam may be performed multiple times during a long transport.
• #32: NOTE: Video clip “ITLS7e Ongoing Exam” will play as a loop (no sound) until next click. NOTE: Click on the screenshot in presentation mode to play the Video clip “ITLS7e Ongoing Exam” in a browser window. Close the browser window to return to the presentation. Ask the patient if there have been any changes in how she feels. Complete the SAMPLE history if not already done. Reassess mental status (LOC and pupils). If the patient has an altered mental status, check a finger-stick glucose and recheck the GCS. Reassess the ABCs. Reassess the airway. Recheck patency. If this is a burn patient, assess for signs of inhalation injury. Reassess breathing and circulation. Recheck vital signs. Note skin color, condition, and temperature. Check the neck for jugular venous distention (JVD) and tracheal deviation. (If a cervical collar has been applied, remove the front to examine the neck.) Recheck the chest. Notice the quality of breath sounds. If breath sounds are unequal, evaluate for splinting, pneumothorax, and hemothorax. Listen to the heart to see if the sounds have become muffled. Reassess the abdomen, if mechanism suggests possible injury. Note the development of tenderness, rigidity, or distention. Check each of the identified injuries (lacerations for bleeding, PMS distal to all injured extremities, flails, pneumothorax, open chest wounds, and so on). Check interventions.
• #33: IMAGE: Figure 2-6: ITLS Secondary Survey. NOTE: Use miniature to conceptualize and demonstrate how survey is a series of steps to be done in sequence without deviation. (Students do not need to be able to read steps on screen.) NOTE: The next series of slides steps through Secondary Survey. Remember: this skill will be taught in skill stations. Secondary Survey is a more comprehensive exam to identify all injuries, not just life-threatening.
• #34: NOTE: ITLS Secondary Survey is taught in skill station. ITLS Secondary Survey: More comprehensive exam to identify all injuries, not just life-threatening. Establishes baseline from which treatment decisions will eventually be made. Important to record information discovered. Whether or not to perform a Secondary Survey as well as when to perform one depends on situation. Critical patients should have this assessment done during transport rather than on scene. Although we say Secondary Survey should be done on critical patients during transport, we have to apply a little common sense. More accurately, we should say “do not delay scene time of a critical patient.” If you are unable to transport, e.g., are waiting for an ambulance/helicopter or patient is being extricated, a Secondary Survey may be performed on scene. If there is a short transport and you must perform interventions, you may not have time to do Secondary Survey. If Primary Survey does not reveal a critical condition, Secondary Survey may be performed on scene. Transport immediately if ITLS Secondary Survey reveals development of any critical trauma situations.
• #35: NOTE: Click on the screenshot in presentation mode to play the Video clip “ITLS7e Secondary Survey” in a browser window. Close the browser window to return to the presentation. NOTE: ITLS Secondary Survey is taught in skill station. Although we say Secondary Survey should be done on critical patients during transport, we have to apply a little common sense. More accurately, we should say “do not delay scene time of a critical patient.” If you are unable to transport, e.g., are waiting for an ambulance/helicopter or patient is being extricated, a Secondary Survey may be performed on scene. DETAILED EXAM of complaints and previously found injuries Exam consists of inspection, auscultation, palpation, and sometimes percussion. Patient history—info not obtained in Primary Survey Complete SAMPLE history. Vital signs—repeat routinely. Measured pulse, respirations, blood pressure Pulse oximeter (SpO2), cardiac monitor (ECG), blood sugar, CO2 monitor (ETCO2). Glasgow Coma Scale Score Eyes, voice, movement, emotional state Head Pupils, Battle's sign, raccoon eyes, drainage; deformities, contusions, abrasions, penetrations, burns, lacerations, swelling, tenderness, instability, crepitation (DCAP-BLS-TIC) Neck DCAP-BLS-TIC. Neck vein distention? Tracheal deviation? Chest Asymmetry; paradoxical motion; DCAP-BLS-TIC Breath sounds Present? Equal? If unequal: percussion. Heart tones, abdomen DCAP-BLS-TIC; rigidity, distention. Pelvis DCAP-BLS-TIC Lower/upper extremities: DCAP-BTLS-TIC; PMS. Posterior: Examine only if not done in ITLS Primary Survey (DCAP-BLS-TIC). At conclusion, finish bandaging and splinting.
• #37: Serum lactate is a marker for tissue hypoxia and has been used in the hospital setting to monitor critical patients. In the field, it appears to be useful to predict which patients with normal vital signs are having occult internal bleeding and will soon develop hemorrhagic shock. Services have been using prehospital finger-stick serum lactate levels to predict who will develop shock. If further studies confirm its predictive value, it will very useful. Portable ultrasound can be used to assess for intraabdominal hemorrhage and cardiac tamponade among other things. Abdominal trauma sonography is very commonly used in the initial assessment of trauma patients in the emergency department and is called the FAST exam (focused assessment with sonography in trauma). It is noninvasive and only takes from one to three minutes to perform.