Initial Assess Trauma

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

1

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

2


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

3


EMS does EMS does NOTNOT have a Golden have a Golden HourHour

EMS has a EMS has a Platinum Ten Platinum Ten MinutesMinutes

4


Patients in Golden Hour must Patients in Golden Hour must be:be:–Recognized quicklyRecognized quickly

–Transported to Transported to APPROPRIATEAPPROPRIATE facilityfacility

5


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

6

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?

7

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!!

8

Primary SurveyPrimary Survey

With critical trauma you With critical trauma you may never get beyond may never get beyond

primary surveyprimary survey

9

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

10

AirwayAirway

Noisy breathing is obstructed Noisy breathing is obstructed breathingbreathing

But all obstructed breathing But all obstructed breathing is not noisyis not noisy

11

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?

13

BreathingBreathing

LookLook

ListenListen

FeelFeel

14

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

15

BreathingBreathing

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

16

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?

20


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

21


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%

22


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!

23


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

24


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

26

Disability (CNS Disability (CNS Function)Function)

Decreased LOC in trauma = Head Decreased LOC in trauma = Head injury until proven otherwiseinjury until proven otherwise

27

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

30

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 !!!!!

31

Initial AssessmentInitial Assessment

If the patient looks If the patient looks sick, he’s sick!!!sick, he’s sick!!!

32

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.

33

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

34

Initial ResuscitationInitial Resuscitation

Minimum Time On Scene

Maximum Treatment In Route

35

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

36

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

38

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

39

Definitive Field CareDefinitive Field Care

Performed Performed ONLYONLY on stable on stable patientspatients

40

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

41

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

42

Health & Medicine

Initial Assess Trauma