Initial Assessment and Initial Assessment and Management of TraumaManagement of Trauma
Capt. Mike BeversCapt. Mike Bevers
Physician’s Assistant, Physician’s Assistant, 173173rdrd MDF MDF
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IntroductionIntroduction
TraumaTrauma–Leading killer from ages 1 Leading killer from ages 1 to 44to 44
–Up to one-third of deaths Up to one-third of deaths are preventableare preventable
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IntroductionIntroduction
Golden HourGolden Hour–Time to reach operating roomTime to reach operating room–NOTNOT time for transport time for transport–NOTNOT time in Emergency time in Emergency DepartmentDepartment
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IntroductionIntroduction
EMS does EMS does NOTNOT have a Golden have a Golden HourHour
EMS has a EMS has a Platinum Ten Platinum Ten MinutesMinutes
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IntroductionIntroduction
Patients in Golden Hour must Patients in Golden Hour must be:be:–Recognized quicklyRecognized quickly
–Transported to Transported to APPROPRIATEAPPROPRIATE facilityfacility
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IntroductionIntroduction
Survival depends on Survival depends on assessment skillsassessment skills
Good assessment results fromGood assessment results from–An organized approachAn organized approach–Clearly defined prioritiesClearly defined priorities
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Size-UpSize-Up
SafetySafety SceneScene
– How does scene look?How does scene look?– How many patients?How many patients?– Where are they?Where are they?
SituationSituation– Additional resources?Additional resources?– Critical vs non-critical patient?Critical vs non-critical patient?
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Initial Assessment Initial Assessment (Primary Survey)(Primary Survey)
Find life threatsFind life threats If life threat present, If life threat present, CORRECT CORRECT
IT!IT! If life threat can’t be correctedIf life threat can’t be corrected
–Support ABCsSupport ABCs–TRANSPORT!!TRANSPORT!!
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Primary SurveyPrimary Survey
With critical trauma you With critical trauma you may never get beyond may never get beyond
primary surveyprimary survey
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Airway with C-Spine Airway with C-Spine Control (if MOI dictates)Control (if MOI dictates)
You don’t need a C-collar yetYou don’t need a C-collar yet
Return head to neutral Return head to neutral positionposition
Stabilize without tractionStabilize without traction
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AirwayAirway
Noisy breathing is obstructed Noisy breathing is obstructed breathingbreathing
But all obstructed breathing But all obstructed breathing is not noisyis not noisy
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AirwayAirway
Anticipate airway problems Anticipate airway problems withwith–Decreased level of consciousnessDecreased level of consciousness–Head traumaHead trauma–Facial traumaFacial trauma–Neck traumaNeck trauma–Upper chest traumaUpper chest trauma
Open it, Clear it, Maintain itOpen it, Clear it, Maintain it12
BreathingBreathing
Is air moving?Is air moving?
Is it moving adequately?Is it moving adequately?
Is oxygen getting to the Is oxygen getting to the blood?blood?
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BreathingBreathing
LookLook
ListenListen
FeelFeel
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BreathingBreathing
Give Oxygen immediately if:Give Oxygen immediately if:–Decreased level of consciousnessDecreased level of consciousness– ? Shock? Shock– ? Severe hemorrhage? Severe hemorrhage–Chest painChest pain–Chest traumaChest trauma–DyspneaDyspnea–Respiratory distressRespiratory distress
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BreathingBreathing
If you think about giving If you think about giving oxygen, GIVE IT!!oxygen, GIVE IT!!
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BreathingBreathing
Consider assisting Consider assisting ventilations if:ventilations if:–Respirations <12Respirations <12
–Respirations >24Respirations >24
–Shallow respirationsShallow respirations
–Respiratory effort increasedRespiratory effort increased 17
BreathingBreathing
If you can’t tell if ventilations If you can’t tell if ventilations are adequate, they aren’t!!are adequate, they aren’t!!
If you are wondering whether If you are wondering whether or not to bag the patient, you or not to bag the patient, you
should!!should!!18
BreathingBreathing
If respirations are If respirations are compromised:compromised:–Expose chestExpose chest
– Inspect front and backInspect front and back
–Palpate front and backPalpate front and back
–Auscultate front and backAuscultate front and back19
CirculationCirculation
Is heart beating?Is heart beating?
Is there serious external Is there serious external bleeding?bleeding?
Is the patient perfusing?Is the patient perfusing?
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CirculationCirculation
Does patient have radial Does patient have radial pulse?pulse?–Absent radial = systolic BP < 80Absent radial = systolic BP < 80
Does patient have carotid Does patient have carotid pulse?pulse?–Absent carotid = systolic BP < Absent carotid = systolic BP < 6060
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CirculationCirculation
No carotid pulse?No carotid pulse?–ExtricateExtricate–CPRCPR–Pneumatic Antishock GarmentPneumatic Antishock Garment–Run!!!!Run!!!!
Survival rate from cardiac Survival rate from cardiac arrest secondary to blunt arrest secondary to blunt trauma is < 1%trauma is < 1%
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CirculationCirculation
Serious external bleeding?Serious external bleeding?–Direct pressure (hand, bandage, Direct pressure (hand, bandage, PASG)PASG)
–Tourniquet as last resortTourniquet as last resort
All bleeding stops eventually!All bleeding stops eventually!
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CirculationCirculation
Is patient in shock?Is patient in shock?–Cool, pale, moist skin = shock, Cool, pale, moist skin = shock, until proven otherwiseuntil proven otherwise
–Capillary refill > 2 sec = shock Capillary refill > 2 sec = shock until proven otherwiseuntil proven otherwise
–Restlessness, anxiety, Restlessness, anxiety, combativeness = shock until combativeness = shock until proven otherwiseproven otherwise
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CirculationCirculation
If possible internal If possible internal hemorrhage, QUICKLY hemorrhage, QUICKLY expose, palpate:expose, palpate:–Abdomen – 2 litersAbdomen – 2 liters
–Pelvis – 2 litersPelvis – 2 liters
–Thighs – 1.5 liter / sideThighs – 1.5 liter / side25
Disability (CNS Disability (CNS Function)Function) Level of Consciousness = Level of Consciousness =
Best brain perfusion indicatorBest brain perfusion indicator
Use AVPU initiallyUse AVPU initially
Check pupilsCheck pupils–The eyes are the window of the The eyes are the window of the CNSCNS
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Disability (CNS Disability (CNS Function)Function)
Decreased LOC in trauma = Head Decreased LOC in trauma = Head injury until proven otherwiseinjury until proven otherwise
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Expose and ExamineExpose and Examine
You can’t treat what you don’t You can’t treat what you don’t find!find!
If you don’t look, you won’t see!If you don’t look, you won’t see! Remove ALL clothing from Remove ALL clothing from
critical patients ASAPcritical patients ASAP Avoid delaying resuscitation Avoid delaying resuscitation
while disrobing patientwhile disrobing patient Cover patient with blanket Cover patient with blanket
when finishedwhen finished28
The “Load and Go” The “Load and Go” SituationsSituations
Head injury with decreased LOCHead injury with decreased LOC Airway obstruction unrelieved by mechanical Airway obstruction unrelieved by mechanical
methodsmethods Conditions resulting in inadequate breathingConditions resulting in inadequate breathing ShockShock Conditions that rapidly lead to shockConditions that rapidly lead to shock
– Tender, distended abdomenTender, distended abdomen– Pelvic instabilityPelvic instability– Bilateral femur fracturesBilateral femur fractures
Traumatic cardiopulmonary arrestTraumatic cardiopulmonary arrest29
Rapid Trauma Rapid Trauma AssessmentAssessment
DCAP-BTLSDCAP-BTLS D - DeformitiesD - Deformities C - ContusionsC - Contusions A - AbrasionsA - Abrasions P - Punctures/PenetrationsP - Punctures/Penetrations B - BurnsB - Burns T - TendernessT - Tenderness L - LacerationsL - Lacerations S - SwellingS - Swelling
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Initial AssessmentInitial Assessment
A blood pressure or an A blood pressure or an exact respiratory or pulse exact respiratory or pulse
rate is NOT necessary to tell rate is NOT necessary to tell that your patient is that your patient is
critical !!!!!critical !!!!!
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Initial AssessmentInitial Assessment
If the patient looks If the patient looks sick, he’s sick!!!sick, he’s sick!!!
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Initial ResuscitationInitial Resuscitation
Treat as you go!Treat as you go!
Aggressively correct hypoxia Aggressively correct hypoxia and inadequate ventilation.and inadequate ventilation.
Control external blood loss.Control external blood loss.
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Initial ResuscitationInitial Resuscitation Immobilize C-spine ? MOI (rigid collar)Immobilize C-spine ? MOI (rigid collar) Keep airway openKeep airway open OxygenateOxygenate Rapidly extricate to long boardRapidly extricate to long board Begin assisted ventilation with BVMBegin assisted ventilation with BVM ExposeExpose Apply and inflate PASGApply and inflate PASG TransportTransport ReassessReassess and report in route and report in route
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Initial ResuscitationInitial Resuscitation
Minimum Time On Scene
Maximum Treatment In Route
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Detailed Exam Detailed Exam (Secondary Survey)(Secondary Survey)
History and Physical ExamHistory and Physical Exam You You WILLWILL get here with get here with MOSTMOST
trauma patientstrauma patients Perform Perform ONLYONLY after initial after initial
assessment is completed and life assessment is completed and life threats correctedthreats corrected
Do Do NOTNOT hold critical patients in hold critical patients in field for detailed examfield for detailed exam
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Physical ExamPhysical Exam
Head to Toe, organized approachHead to Toe, organized approach
Every patient, same way, every Every patient, same way, every timetime
Top to bottom; near to far, front Top to bottom; near to far, front & back& back
Look--Listen--FeelLook--Listen--Feel37
HistoryHistory
Chief complaintChief complaint–What What PATIENTPATIENT says says problem isproblem is
–Not necessarily what you Not necessarily what you seesee
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HistoryHistory
A = AllergiesA = Allergies M = MedicationsM = Medications P = Past medical historyP = Past medical history L = Last oral intakeL = Last oral intake E = Events leading up to E = Events leading up to
incidentincident
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Definitive Field CareDefinitive Field Care
Performed Performed ONLYONLY on stable on stable patientspatients
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Definitive Field CareDefinitive Field Care
Stable patients can receive attention Stable patients can receive attention for individual injuries before transportfor individual injuries before transport– BandagingBandaging– SplintingSplinting
Reassess carefully for hidden Reassess carefully for hidden problemsproblems
If patient becomes unstable at any If patient becomes unstable at any time,time, TRANSPORTTRANSPORT
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ReevaluationReevaluation
Ventilation and perfusion statusVentilation and perfusion status
Repeat vital signsRepeat vital signs
Continued stabilization of Continued stabilization of identified problemsidentified problems
Continued reassessment for Continued reassessment for unidentified problemsunidentified problems
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