Aaron Markwith, CCEMTP Valencia College Paramedic Laboratory I

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Initial Assessment

Focused Trauma Assessment

Rapid Trauma Assessment

Ongoing Assessment

Cannot be emphasized enough ◦ Priorities

1. Yourself

2. Your Crew

3. The Patient

4. Bystanders

Don’t let anything deter you from that.

Don’t be a hero

BSI ◦ PPE

Is this a Trauma or a Medical patient? ◦ If medical, determine

the nature of illness (NOI)

◦ If Trauma, determine the mechanism of injury (MOI)

Check the number of patients ◦ Mass Casualty

Incident (MCI Establish Command

Call for more units

Triage patients

Ensure you have adequate resources for your patient. ◦ Fire Department

Extrication

Multiple patients

HAZMAT

Manpower

Roadway safety

◦ Police

Ensure scene safety

Violent bystanders/patient

Forced entry to residence/business

Determine the Age/Sex of patient

Position Found ◦ Skin color

Work of Breathing

Level of Anxiety

If trauma is suspected, assign someone to hold c-spine

IMMEDIATELY. Holding c-spine is a critical intervention, if it is not done IMMEDIATELY, you will fail

your scenario

First, check how responsive the patient is:

◦ Alert If alert, are they

oriented? Person Place Time Event

If the patient is only alert 3 of the 4, you would say he is A&O x 3.

If he was alert to 2 of the 4 then he is A&O x 2 etc.

Alert to Verbal Stimuli ◦ Make a loud noise

◦ Clap your hands in

front of the patient’s face

◦ Determine the reason for this level of consciousness

Alert to Painful Stimuli ◦ Sternal Rub Make a fist and firmly

rub back and forth on the patient’s sternum

◦ Pen Test Take your pen and push

it hard on the patient’s knuckles

Unresponsive ◦ Patient does not

respond to ANYTHING you try

Used to help quantify AMS

The highest score you can get is a 15

The Lowest Score you can get is a 3 ◦ “A rock gets a 3”

Broken down into 3

sections ◦ Eyes (1-4)

◦ Verbal (1-5)

◦ Motor (1-6)

Does the patient have their eyes open when you walk up? ◦ Score 4

Does the Patient open their eyes to verbal stimuli? ◦ Score 3

Does the patient open their eyes to painful stimuli? ◦ Score 2

The patient will not open their eyes at all, regardless of stimulation. ◦ Score 1

Does the patient speak coherently and normally? ◦ Score 5

Is the patient confused or disoriented? ◦ Score 4

Wind are puppies

joy fellow snow

boat fell

Ugg rthh dohh

quiinnn

Does the patient use inappropriate words? ◦ Score 3

Does the patient just mumble sounds? ◦ Score 2

Does the patient not speak, nor make any other sounds? ◦ Score 1

Does your patient obey commands? ◦ Score 6

Does the patient localize pain? ◦ Score 5

Does the patient withdraw from pain? ◦ Score 4

Does the patient demonstrate decorticate posturing (bringing arms to the “core”) ◦ Score 3

Does the patient show signs of decerebrate posturing? ◦ Score 2

Does the patient show no signs of movement regardless of stimulation? ◦ Score 1

GCS >8 ◦ Many times a patient

with a GCS >8 requires airway protection…in other words, we may need to intubate the patient

Total score ≥ 13 ◦ Minor

Total score = 9-12 ◦ Moderate

Total Score ≤ 8 ◦ Severe

In a conscious patient assign someone to check pulse ◦ Rate Fast or slow

◦ Rhythm Regular or Irregular

◦ Quality Strong or weak

Assign someone to check respirations ◦ Rate Fast or slow

◦ Rhythm Regular or Irregular

◦ Depth Deep or Shallow

If the patient is pulseless:

◦ One or two rescuer: Begin chest

compressions of 30:2

5 cycles for 2 min

If the patient has AMS and inadequate respirations: ◦ Open airway with head-tilt

chin lift Jaw Thrust if trauma

suspected

◦ Ventilate 1 breath every 5-6 seconds

◦ Each breath over 1 second

◦ Attach to 15lpm O2 Don’t delay BVM for O2 Don’t forget O2

◦ Insert airway adjunct Don’t delay BVM for airway

adjunct

Oral Pharyngeal Airway (OPA)

Nasal Pharyngeal Airway (NPA

Size by measuring from the corner of the mouth to the angle of the jaw ◦ If it is too big it will

obstruct the airway

◦ If it is too small it will block the airway with the tongue

Insert in the mouth

inversely or side-ways

As you reach the back of the mouth turn it into place

Contraindications: ◦ Gag Reflex

◦ Alert Patient

NPA ◦ Also called a “Nasal

Trumpet”

Size the device by measuring from the tip of the nose to the bell of the ear

Choose the larger of the nares

Lubricate the NPA

Place bevel to the

septum ◦ Left nare You will need to twist the

NPA once resistance is met to follow the anatomy of the body

Advance until the

airway is flush with the nose

Contraindications ◦ Suspected basilar

skull fracture

ALWAYS place your patient on Oxygen ◦ It is a critical

intervention!

◦ Don’t fail your scenario over this!

Nasal Cannula ◦ Used when there is no

respiratory distress

◦ 1-6 liters per minute

◦ Can deliver 24-44% FiO2 (Fractional inspired Oxygen)

Non-Rebreather Mask ◦ Flow at 10-15 liters per

minute

◦ Ensure the reservoir bag remains at least 2/3 full with each breath

◦ Can deliver >90% FiO2

◦ Used with respiratory distress

Disability ◦ Obvious disabilities Open fractures, etc.

Expose ◦ Vital to identify life

threatening problems

CUPS ◦ Critical

Emergent transport

◦ Unstable

Emergent transport

◦ Potentially Unstable

Emergent or urgent transport

◦ Stable

Urgent transport

REMEMBER PATIENT CONDITION CAN CHANGE EN ROUTE!

Used when there a non-significant mechanism of injury

The Focused Trauma Assessment for the injured site is the same as the corresponding Detailed Trauma Assessment

From start to finish, the Rapid Trauma Assessment (RTA) should

take less than 120 seconds

DCAP-BTLS ◦ Deformities ◦ Contusions ◦ Abrasions ◦ Punctures/Penetrations ◦ Burns ◦ Tenderness ◦ Lacerations ◦ Swelling

DCAP-BTLS ◦ Assess for blood or fluid in

the eyes (hyphema)

◦ Assess pupils If unequal suspect head injury

and transport EMERGENTLY

◦ Assess for blood or fluid in

the ears

◦ Assess for blood or fluid in the mouth

DCAP-BTLS ◦ Check for Tracheal Deviation

Assess lung sounds

If life threatening emergency identified, treat on scene

◦ Check for jugular vein distention

◦ Feel for cervical step-down Whether it is felt or not, apply c-

collar if cervical trauma is suspected

C-Collar is a Critical Intervention PRIOR to log roll

DCAP-BTLS ◦ Check for

subcutaneous emphysema Free air under the skin

Sign of punctured lung

Feels like crushed Styrofoam under the skin

DCAP-BTLS ◦ Listen the Lung sounds

If pleural decompression is required use 14g 2-4 inch catheter and decompress on 2nd to 3rd intercostal space

Only decompress a Tension Pneumothorax

◦ TIC Tenderness

Make note of it, nothing to do as far as interventions

Instability

Secure with bulky dressing if flail segment noted

Crepitus

Secure with bulky dressing if flail segment is noted

Observe for paradoxical motion

DCAP-BTLS

◦ One quick squeeze

on the abdomen

DCAP-BTLS ◦ TIC Tenderness

Observe and report

Instability

Stabilize on LBB

Crepitus Stabilize on LBB

◦ Suspect 2 liters of blood

loss from a Fractured Pelvis

DCAP-BTLS

◦ Only treat life threatening emergencies on scene

◦ Check Babinski reflex Normal toes flex forward

Abnormal (positive Babinski) toes flare outward (sign of increased ICP)

DCAP-BTLS ◦ Only treat life

threatening emergencies on scene

Ensure C-Collar in place!

Carefully log roll the patient

DCAP-BTLS

Move patient to ambulance ◦ Reassess the ABC’s

◦ Get the first set of V/S

Blood Pressure

Heart Rate

Respiratory Rate

Skin Color

Pupils

Attach 3-lead ECG

Establish 2 large bore IV’s ◦ Attached to 2 1,000mL NS

bags

◦ Do not necessarily need to run both wide open

Connect SpO2 and EtCO2

DCAP-BTLS ◦ Assess for blood or fluid in the

eyes (hyphema) ◦ Assess pupils

If unequal suspect head injury and transport EMERGENTLY

◦ Assess for blood or fluid in the

ears Halo Test

◦ Assess for blood or fluid in the

mouth Check for any other obstructions (i.e.

teeth)

◦ Assess for Battle Signs (retroauricular ecchymosis) Sign of a basilar skull

fracture…do not use NPA

◦ Assess for Raccoon Eyes (Bilateral periorbital ecchymosis) Sign of a basilar skull

fracture…do not use NPA

DCAP-BTLS ◦ Difficult to reassess with

C-Collar in place Re-Check for Tracheal

Deviation Assess lung sounds

If life threatening emergency identified, treat on scene

Re-Check for jugular vein distention If Present, possible Cardiac

Tamponade or Tension Pneumothorax

DCAP-BTLS ◦ Re-Check for

subcutaneous emphysema

DCAP-BTLS ◦ Listen the Lung sounds

If pleural decompression is required use 14g 2-4 inch catheter and decompress on 2nd to 3rd intercostal space

Only decompress a Tension Pneumothorax

◦ TIC Tenderness

Make note of it, nothing to do as far as interventions

Instability

Secure with bulky dressing if flail segment noted

Crepitus

Secure with bulky dressing if flail segment is noted

Observe for paradoxical motion

DCAP-BTLS ◦ Assess for rigidity If rigidity found, transport

emergently to ER

◦ Assess for distention If present, emergently

transport to the ER

◦ Assess for pulsing masses

◦ Give fluids as needed to keep BP >90mmHg Systolic

DCAP-BTLS ◦ If a fractured pelvis was

noted prior, do not push on the pelvis again Duh!

◦ Suspect 2 liters of blood loss from a Fractured Pelvis

◦ Assess BP and give fluids to keep BP >90mmHg Systolic

DCAP-BTLS ◦ Pulse check

Dorsalis Pedis

Posterior Tibialis

◦ Motor

Check to see if patient obeys commands

Check equality of strength in legs

◦ Sensation Identify which toe you are touching

Check nervous reaction Babinski Reflex

DCAP-BTLS ◦ Check Radial Pulse

◦ Motor Grip strength Equal?

◦ Sensation Nervous Reaction

Difficult to do when patient is on LBB

Continually reassess your patient ◦ CAB’s

Reassess the interventions

◦ Response to your medications i.e. recheck a blood sugar

Reassess Blood pressure post fluids

Reassess your vital signs

◦ Stable Patient every 15min

◦ Unstable Patient every 5min

Always treat new problems as they arise, remember that the patient condition can change en route!

Remember, a good

assessment can be the difference between life and

death!

Airway burns: ◦ Make sure you secure the

airway as soon as possible with an ETT Singed Nasal Hairs

Burns around the mouth

and nose

Prolonged exposure to fire/smoke

Consider Surgical Airways if Necessary

Tension Pneumothorax ◦ HYPOtension

BP < 90mmHg Systolic

Lack of radial pulse

◦ Difficulty Breathing

◦ Diminished/Absent unilateral breath

sounds

◦ Tracheal Deviation

◦ May be used with an open chest wound ONLY AFTER THE OCCLUSIVE DRESSING HAS BEEN “BURPED”

Ensure appropriate BSI ◦ Gloves ◦ Eye Protection

Prepare Equipment ◦ Always gather the

appropriate equipment prior to beginning the procedure

Clean the site with iodine pad ◦ If iodine contraindicated,

clean the site twice with alcohol prep

Take a 14g 2-4 inch needle, remove the cap from the back of the needle

Identify the landmark ◦ 2nd intercostal space

◦ Between the second and

third rib ◦ Midclavicular

◦ Always place the needle

ABOVE the third rib, not beneath the second

If the needle is placed too medially then you run the risk of puncturing the heart

If a tension pneumothorax is misdiagnosed then you run the risk of lung trauma or creating a pneumothorax

Insert the needle until you hear/feel air coming from the needle

Remove the needle and place in the sharps box

Stabilize the catheter with 4x4s and tape

Repeat as necessary ◦ To repeat, go RIGHT NEXT to the

initial site

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