Assessment of the Trauma Patient
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1 CHAPTER 10 Assessment of the Trauma Patient
2 Overall Assessment Scheme Scene Size-Up Initial Assessment Trauma Physical Exam Vital Signs & SAMPLE History Medical SAMPLE History Physical Exam & Vital Signs Detailed Physical Exam Ongoing Assessment HOSP
3 Assessing the Trauma Patient Is there a significant mechanism of injury? Yes Perform a rapid assessment. No Perform a focused assessment.
4 Mechanism of Injury
5 Significant Mechanism of Injury
6 Significant Mechanism of Injury Ejection from vehicle Death in same passenger compartment Fall of greater than 15 feet or 3 times the patient s height
7 Significant Mechanism of Injury Rollover of vehicle High-speed vehicle collision Vehicle-pedestrian collision
8 Significant Mechanism of Injury Motorcycle crash Unresponsive or altered mental status Penetrating injury of head, chest, or abdomen
9 Significant Mechanism of Injury Infants and Children Falls greater than 10 ft. Bicycle collision Vehicle in mediumspeed collision
10 Mechanism of Injury: Interior of Vehicle Deformities to a vehicle s interior may show where person struck the surface and reveal a mechanism of injury.
11 Bent Steering Wheel
12 Broken Mirror
13 Distorted Pedals
14 Spider-Webbed Windshield
15 Deformed Dashboard
16 If Significant Mechanism of Injury Reconsider mechanism of injury. Assess mental status. Continue spine stabilization. Perform a rapid trauma assessment.
17 Rapid Trauma Assessment
18 Inspect and Palpate for DCAP-BTLS D C A P = = = = Deformities Contusions Abrasions Punctures/ Penetrations B T L S = = = = Burns Tenderness Lacerations Swelling
19 Deformities
20 Contusions
21 Abrasions
22 Punctures/Penetrations
23 Burns
24 Tenderness
25 Lacerations
26 Swelling
27 Rapid Trauma Assessment Head Neck Chest Abdomen Pelvis Extremities Posterior
28 Head: DCAP-BTLS + Crepitation
29 Neck: DCAP-BTLS + Jugular Vein Distention and Crepitation
30 Chest: DCAP-BTLS + Crepitation and Breath Sounds (Presence and Equality)
31 Listen to both sides of the chest. Is air entry present? Absent? Equal on both sides? Compare left side to right side. Mid-axillary Mid-clavicular
32 Abdomen: DCAP-BTLS + Firmness and Distention
33 Pelvis: DCAP-BTLS (Compress( gently.)
34 Extremities: DCAP-BTLS + Distal Pulse, Sensation, Motor Function
35 Posterior: DCAP-BTLS
36 Significant Mechanism of Injury Assess baseline vital signs. Obtain SAMPLE history. Consider requesting ALS. Reconsider transport decision.
37 Transport
38 If No Significant Mechanism of Injury Reconsider mechanism of injury. Determine chief complaint. Perform focused physical exam based on: Chief complaint Mechanism of injury
39 No Significant Mechanism of Injury Use DCAP-BTLS on focused area of assessment. Assess baseline vital signs. Obtain SAMPLE history.
40 Vital Signs Respirations Pulse Skin color, temperature, condition Pupils Blood Pressure
41 SAMPLE History S A M P L E = Signs and symptoms = Allergies = Medications = Pertinent past history = Last oral intake = Events leading to injury or illness
42 Rules of Assessment Explain to the patient what you are doing. Expose areas before assessing. Assume spinal injury.
43 Cervical Collar Sizing and Application
44 Cervical Collars STIFNECK TM Rigid Extrication Collar Philadelphia Cervical Collar TM
45 STIFNECK TM Collar Seated Patient Stabilize head and neck manually.
46 Sizing a Cervical Collar 2 Measure the collar. 1 Measure the patient s neck.
47 STIFNECK TM Collar Seated Patient Slide collar up toward patient s chin.
48 STIFNECK TM Collar Seated Patient Position front of collar under chin.
49 STIFNECK TM Collar Seated Patient Wrap collar around back of neck.
50 STIFNECK TM Collar Seated Patient Secure the collar.
51 STIFNECK TM Collar Seated Patient Rearrange fingers to maintain support.
52 STIFNECK TM Collar Supine Patient Kneel at patient s head.
53 STIFNECK TM Collar Supine Patient Stabilize the head and neck.
54 STIFNECK TM Collar Supine Patient Maintain stabilization.
55 STIFNECK TM Collar Supine Patient Slide back of collar under patient s neck.
56 STIFNECK TM Collar Supine Patient Secure collar.
57 STIFNECK TM Collar Supine Patient Maintain manual stabilization.
58 Detailed Physical Exam
59 Who Needs a Detailed Physical Exam? Determined by patient s condition: After critical interventions for a patient with significant MOI Occasionally for a patient with no significant MOI Rarely for a medical patient
60 Who Needs a Detailed Physical Exam? You may never have time to perform a detailed exam on a patient with critical injuries.
61 Steps in the Detailed Physical Exam
62 The Detailed Physical Exam Assess areas examined in rapid trauma assessment plus: Face Ears Eyes Nose Mouth
63 The Detailed Physical Exam Examine slower than during rapid trauma assessment. Often do during transport. Reassess vital signs.
64 DCAP-BTLS D C A P = = = = Deformities Contusions Abrasions Punctures/ Penetrations B T L S = = = = Burns Tenderness Lacerations Swelling
65 Head DCAP-BTLS
66 Ears DCAP-BTLS + Drainage
67 Eyes DCAP-BTLS + Discoloration Unequal pupils Foreign bodies Blood in anterior chamber
68 Nose and Mouth DCAP-BTLS + Teeth Obstructions Swollen or lacerated tongue
69 Nose and Mouth DCAP-BTLS + Odors Discoloration Drainage Bleeding
70 Neck: Assessment Limited by Cervical Collar
71 Chest: Reassess Breath Sounds Presence and Equality
72 The Detailed Physical Exam The abdomen, pelvis, and extremities may have already been assessed during rapid trauma assessment. If not yet done, assess these areas thoroughly
73 Extremities: Reassess Distal Pulse, Sensation, Motor Function
74 Perform the steps of the Rapid Trauma Assessment BUT MORE SLOWLY.
75 Reassess Vital Signs Respirations Pulse Skin color, temperature, condition Pupils Blood pressure
76 Review Questions 1. When should you perform a detailed physical exam? 2. Explain the letters DCAP-BTLS. 3. What do you assess in the detailed physical exam that you don t assess in the rapid trauma assessment?
77 Review Questions 4. List some significant mechanisms of injury. 5. List the steps of the focused history and physical exam for the trauma patient with a significant mechanism of injury.
78 Review Questions 6. List the steps of the rapid trauma assessment. 7. List the signs and symptoms that correspond to DCAP-BTLS. 8. Tell what each of the letters in SAMPLE stands for.
79 Review Questions 9. Describe how to apply a STIFNECK TM collar to a seated patient. To a supine patient. 10. List the steps in the focused history and physical exam for the trauma patient with no significant mechanism of injury.
80 STREET SCENES What is the priority of this patient? What should be done next? When should vital signs be taken?
81 STREET SCENES What should you do next? What should be done for the detailed assessment if there is time before reaching the trauma center?
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