Assessment and Initial Management of the Trauma Patient

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

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ITLS Patient Assessment

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

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ITLS Primary Survey

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

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Scene Size-up
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Scene Size-up
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Initial Assessment
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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

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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
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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.

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ITLS Primary Survey

• Initial Level of Consciousness
• Cervical-spine stabilization
• Alert
• Responds to Verbal stimuli
• Responds to Pain
• Unresponsive

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ITLS Primary Survey

• Airway look, listen, feel
• Direct simple positioning and suctioning
• If not adequate, not quickly correctable
• Interrupt advanced airway techniques

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ITLS Primary Survey

• Breathing look, listen, feel
• Direct high-flow oxygen
• If not adequate
• Direct assisted ventilation

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Breathing Rates
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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

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MOI Decision

• Dangerous generalized or unconscious
• Rapid Trauma Survey
• Dangerous focused
• Focused Exam
• Not significantInitial Assessment normal
• Focused Exam

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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

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Rapid Trauma Survey
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Rapid Trauma Survey

• Inspect Head and Neck
• Major Facial Injuries, Bruising, Swelling,
  Penetrations, Subcutaneous Emphysema
• Neck Vein Distention? Tracheal Deviation?

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Rapid Trauma Survey

• Inspect Chest
• Asymmetry, Contusion, Penetrations, Paradoxical
  Motion, Instability, Crepitation
• Breath Sounds
• Present? Equal?
• (If unequal Percussion)
• Heart Tones

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Rapid Trauma Survey

• Abdomen
• Bruising, Penetration/Evisceration, Tenderness,
  Rigidity, Distention
• Pelvis
• Tenderness, Instability, Crepitation

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Rapid Trauma Survey

• Lower/Upper Extremities
• Swelling, Deformity, Instability, Motor, Sensory
• Place Patient on Backboard
• Posterior
• Penetrations, Deformity, Presacral Edema

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Rapid Trauma Survey

• If critical situation,transfer to ambulance to
  complete exam.

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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

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Glasgow Coma Scale
Decorticate posturing to pain Decerebrate
posturing to pain
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Brief Targeted History

• S Symptoms
• A Allergies
• M Medications
• P Past medical history
• L Last oral intake
• E Events preceding incident

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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 MOI and/or poor general health
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• When in doubttransport early!

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Critical Interventions

• On-scene procedures

• Manage airway
• Assist ventilation
• Administer oxygen
• Begin CPR
• Control major external bleeding

• Seal sucking chest
• Stabilize flail chest
• Decompress tension pneumothorax
• Stabilize impaled
• Complete packaging

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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

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ITLS Secondary Survey
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ITLS Secondary Survey

• More comprehensive exam
• Evaluation for all injuries, not just
  life-threatening
• Establishes baseline for treatment decisions
• Performed
• Critical patientsdone during transport
• Short transportmay not have time
• Non-critical patientsdone on scene

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ITLS Secondary Survey

• Initial Assessment
• Repeat routinely
• Vital signs
• Repeat routinely
• Monitoring
• Detailed Exam
• Head-to-toe
• DCAP-BTLS

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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?

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Detailed Exam DCAP-BTLS

• Deformities
• Contusions
• Abrasions
• Penetrations

• Burns
• Tenderness
• Lacerations
• Swelling

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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, Battles Sign, Raccoon Eyes, Drainage
• DCAP-BTLS

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ITLS Secondary Survey

• Neck
• DCAP-BTLS Neck Vein Distention? Tracheal
  Deviation?
• Chest
• Asymmetry Paradoxical Motion DCAP-BTLSTenderne
  ss, Instability, Crepitation TIC
• Breath Sounds
• Present? Equal?
• (If unequal Percussion)
• Heart Tones

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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

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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

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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

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Summary

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

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Discussion