Initial Assessment and Management of Trauma

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Initial Assessment and Management of Trauma

• Temple College
• EMS Professions

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Introduction

• Trauma
• Leading killer from ages 1 to 44
• Up to one-third of deaths are preventable

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Introduction

• Golden Hour
• Time to reach operating room
• NOT time for transport
• NOT time in Emergency Department

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Introduction

• EMS does NOT have a Golden Hour
• EMS has a Platinum Ten Minutes

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Introduction

• Patients in Golden Hour must be
• Recognized quickly
• Transported to APPROPRIATE facility

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Introduction

• Survival depends on assessment skills
• Good assessment results from
• An organized approach
• Clearly defined priorities

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Size-Up

• Safety
• Scene
• How does scene look?
• How many patients?
• Where are they?
• Situation
• Additional resources?
• Critical vs non-critical patient?

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Initial Assessment (Primary Survey)

• Find life threats
• If life threat present, CORRECT IT!
• If life threat cant be corrected
• Support ABCs
• TRANSPORT!!

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Primary Survey

• With critical trauma you may never get beyond
  primary survey

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Airway with C-Spine Control

• You dont need a C-collar yet
• Return head to neutral position
• Stabilize without traction

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Airway with C-Spine Control

• Noisy breathing is obstructed breathing
• But all obstructed breathing is not noisy

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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

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Breathing

• Is air moving?
• Is it moving adequately?
• Is oxygen getting to the blood?

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Breathing

• Look
• Listen
• Feel

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Breathing

• Oxygenate immediately if
• Decreased level of consciousness
• ? Shock
• ? Severe hemorrhage
• Chest pain
• Chest trauma
• Dyspnea
• Respiratory distress

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Breathing
If you think about giving oxygen, GIVE IT!!
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Breathing

• Consider assisting ventilations if
• Respirations lt12
• Respirations gt24
• Tidal volume decreased
• Respiratory effort increased

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Breathing
If you cant tell if ventilations are adequate,
they arent!!
If you are wondering whether or not to bag the
patient, you should!!
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Breathing

• If respirations compromised
• Expose chest
• Inspect front and back
• Palpate front and back
• Auscultate front and back

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Circulation

• Is heart beating?
• Is there serious external bleeding?
• Is the patient perfusing?

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Circulation

• Does patient have radial pulse?
• Absent radial systolic BP lt 80
• Does patient have carotid pulse?
• Absent carotid systolic BP lt 60

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Circulation

• No carotid pulse?
• Extricate
• CPR
• Pneumatic Antishock Garment
• Run!!!!
• Survival rate from cardiac arrest secondary to
  blunt trauma is lt 1

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Circulation

• Serious external bleeding?
• Direct pressure (hand, bandage, PASG)
• Tourniquet as last resort
• All bleeding stops eventually!

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Circulation

• Is patient in shock?
• Cool, pale, moist skin shock, until proven
  otherwise
• Capillary refill gt 2 sec shock until proven
  otherwise
• Restlessness, anxiety, combativeness shock
  until proven otherwise

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Circulation

• If possible internal hemorrhage, QUICKLY expose,
  palpate
• Abdomen
• Pelvis
• Thighs

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Disability (CNS Function)

• Level of Consciousness Best brain perfusion
  indicator
• Use AVPU initially
• Check pupils
• The eyes are the window of the CNS

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Disability (CNS Function)
Decreased LOC in trauma Head injury until
proven otherwise
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Expose and Examine

• You cant treat what you dont find!
• If you dont look, you wont see!
• Remove ALL clothing from critical patients ASAP
• Avoid delaying resuscitation while disrobing
  patient
• Cover patient with blanket when finished

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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

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Initial Assessment

• A blood pressure or an exact respiratory or pulse
  rate is NOT necessary to tell that your patient
  is critical !!!!!

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Initial Assessment

• If the patient looks sick, hes sick!!!

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Initial Resuscitation

• Treat as you go!
• Aggressively correct hypoxia and inadequate
  ventilation.
• Control external blood loss.

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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

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Initial Resuscitation

• Minimum Time On Scene
• Maximum Treatment In Route

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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

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Physical Exam

• Stepwise, organized
• Every patient, same way, every time
• Superior to inferior proximal to distal
• Look--Listen--Feel

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History

• Chief complaint
• What PATIENT says problem is
• Not necessarily what you see

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History

• A Allergies
• M Medications
• P Past medical history
• L Last oral intake
• E Events leading up to incident

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Definitive Field Care

• Performed ONLY on stable patients

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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

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Reevaluation

• Ventilation and perfusion status
• Repeat vital signs
• Continued stabilization of identified problems
• Continued reassessment for unidentified problems