1. Focused History and Physical Examination of the Trauma Patient
Chapter 14
Focused History and Physical Examination of the Trauma Patient

2. Overview Determination of Trauma The Rapid Trauma Assessment
The Focused Trauma Assessment
Activity: Divide the class into groups of four to five students and have them answer the questions in the case, “High Speed Rollover.” Bring the class back together and have each group report on their responses.
Suggested Responses:
1. Based on the high energy involved in a motor vehicle collision, the patient should have a rapid trauma assessment performed.
2. Both the rollover of the vehicle and the crushed roof would lead the EMT to suspect multiple impacts with the interior of the vehicle and possible serious injury as a result.
3. Depending on the mechanism of injury, this patient would be a high-priority patient.

3. Determination of Trauma
The objective of the initial assessment is to discover and treat life threatening injuries
Immediate transportation quickly follows when the patient is seriously ill or injured
The EMT should continue the assessment, giving special attention to injuries
The objective of the initial assessment of the trauma patient is to discover and treat life threatening injuries. However, if this assessment is completed and no immediate life threat is discovered, a focused history and physical examination will allow the EMT to find injuries that may not have been apparent yet. She can provide field stabilization to these injuries before transportation.

4. Determination of Trauma
Complete head-to-toe rapid trauma assessment for major mechanism of injury
Focused trauma assessment for minor isolated trauma
Whenever a major mechanism of injury is encountered, the EMT should perform a complete head-to-toe rapid trauma assessment. In cases where there is minor isolated trauma, the EMT should perform a focused trauma assessment based on the patient’s specific injury.
After the focused trauma assessment is, the EMT should obtain a baseline set of vital signs as well as a SAMPLE history. In some cases, the injury is treated at the same time as the vital signs are taken, or immediately after.

5. Determination of Trauma
General principles of physical examination
Touching a patient is considered performing a medical examination
The relationship between the EMT and the patient is based on trust and respect
When an EMT touches a patient she is assessing, she is performing a medical examination. The EMT is exercising a relationship similar to the physician-patient relationship when doing this. It is an EMT’s duty to gain the patient’s trust and maintain respect for him.

6. Determination of Trauma
General principles of physical examination
Be polite
Maintain the patient’s privacy
Be honest
Focus the patient’s attention
Every EMT should exercise the following principles when performing a physical examination:
Be polite.
Offer explanations.
Maintain the patient’s privacy.
Make eye contact.
Be honest.
Focus the patient’s attention.
At times patients’ reactions are based on fear and confusion. The EMT should make an effort to remain professional at all times.

7. Determination of Trauma
Reconsider the mechanism of injury
What cannot be seen can kill a patient
Consider the worst case scenario
Have a high index of suspicion
The mechanism of injury for a trauma patient can be thought of as the history of the present illness. The EMT should gather as many details as she can regarding the mechanism of injury.
In many trauma cases it is not what can be seen that will kill the patient, it is what cannot be seen.
Reconsider the mechanism of injury and ask yourself, “In the worst case scenario, what injuries could this patient have?”
A serious mechanism of injury will create a high index of suspicion that a severe hidden injury may exist.

8. Determination of Trauma
Reconsider the mechanism of injury
A serious mechanism calls for a rapid trauma assessment
A minor mechanism can have a major impact
Consider ALS backup
Whenever an EMT discovers a serious mechanism of injury, a rapid trauma assessment should be completed.
Often a seemingly minor mechanism can have a major impact, especially in certain patient populations. Elderly patients and patients with chronic illness are often highly susceptible to serious injury, even if the mechanism seems minor. A patient who was not wearing a seat belt at the time of a crash and may have bounced around in the vehicle would also be considered high risk.
Consider ALS backup if there are unstable vital signs, significant physical injuries, or a significant past medical history.

9. The Rapid Trauma Assessment
Initial assessment and rapid trauma assessment
Should take about one or two minutes to complete
Continually reassess ABCs
Any trauma patient who has been exposed to a significant mechanism of injury should undergo an initial assessment followed by a rapid trauma assessment. During the rapid trauma assessment, the EMT is looking for indications of obvious or hidden trauma. It is geared to identifying injuries that are not initially obvious yet may be quite serious.
This should take about one or two minutes to complete.
3. Continually reassess ABCs; any changes require stopping the rapid trauma assessment and resolving the life threatening problem.

10. The Rapid Trauma Assessment
Physical signs of injury
DCAP-BTLS
The signs an EMT looks for that may indicate serious underlying injuries are abbreviated by the initials DCAP-BTLS. The EMT should memorize this abbreviation and use it every time she does a rapid trauma assessment.

11. The Rapid Trauma Assessment
Physical signs of injury
D: Deformity
Any irregularity outside of the normal body shape should be considered a deformity and possibly the result of trauma. Deformity is often the first indication of a broken or fractured bone under the skin.
Courtesy of Dr. Deborah Funk, Albany Medical Center, Albany, NY

12. The Rapid Trauma Assessment
Physical signs of injury
C: Contusion
Another word for bruise
Result from blood pooling under the skin
Potentially serious
A layperson’s term for a contusion is bruise. Contusions are a result of blood pooling under the skin and should be considered a sign of potentially serious internal injuries. They usually take around 15–20 minutes to form and therefore may not be immediately apparent to the EMT.

13. The Rapid Trauma Assessment
Physical signs of injury
A: Abrasion
Skin is scraped and underlying tissue is exposed
Shows where force was applied to the body
Abrasions occur whenever the skin is scraped and underlying tissue is exposed. A skinned knee from a fall off a bike is an example of an abrasion.
An abrasion by itself is not serious, but it delineates the area where force was applied, as in a fall.
Courtesy of Dr. Deborah Funk, Albany Medical Center, Albany, NY

14. The Rapid Trauma Assessment
Physical signs of injury
P: Puncture
Caused by an object penetrating the skin and underlying tissue
May be very deep
Should be considered serious
A puncture wound is an injury caused by an object penetrating the skin and soft tissues. Puncture wounds can be quite deep despite a relatively small skin wound. Any penetrating wound to the head, neck, chest, abdomen, or pelvis should be considered serious and should be reported to the hospital staff immediately so that further assessment of underlying organs may be quickly initiated.
Courtesy of Dr. Deborah Funk, Albany Medical Center, Albany, NY

15. The Rapid Trauma Assessment
Physical signs of injury
B: Burn
Should be considered serious
Can result in infection or hypovolemia
Burns are created whenever a significant source of heat damages the outer layer of the skin. Burns involving the hands, face, feet, or genitals is considered a serious burn regardless of the depth of the burned skin, and any burn can result in infection and hypovolemia. They should be noted and reported to the staff at the emergency department.
Courtesy of Dr. Deborah Funk, Albany Medical Center, Albany, NY

16. The Rapid Trauma Assessment
Physical signs of injury
T: Tenderness
Gently assess the skin for underlying pain
The patient will usually show some sign of pain
While assessing the patient, the EMT should be gently pressing her fingertips against the skin.
Any area that is sensitive or even painful to the touch is said to be tender. Signs of tenderness include a facial grimace or guarding of the injured area; the patient may even push the EMT’s hand away from his body. If the area is tender, the patient will usually complain of pain, a symptom.

17. The Rapid Trauma Assessment
Physical signs of injury
L: Laceration
A deep cut in the skin
Need to be sutured
Any deep cuts in the skin called lacerations should be noted and reported. Lacerations can indicate where a significant external force was applied to the body. They often need to be sutured or sewn closed.
Courtesy of Dr. Deborah Funk, Albany Medical Center, Albany, NY

18. The Rapid Trauma Assessment
Physical signs of injury
S: Swelling
Can be difficult to assess
Compare both sides of the body
The EMT should note any swelling under the skin. This last sign can be difficult to assess; the best method of determining whether something is swollen is to compare the suspect area with the other side of the body. Often an EMT can feel that one leg is more swollen than the other, though it may be difficult to see.

19. The Rapid Trauma Assessment
Steps of the rapid trauma assessment
Head and neck
Check the head thoroughly
Assess the neck and trachea
Start at the head and methodically work your way down the patient’s body looking for DCAP-BTLS. Injuries to the head and neck are often very serious. Bleeding can cause problems with the airway. Blows to the head can injure delicate brain tissue, causing the patient to lose consciousness.
1. Check the head thoroughly: Check the bones of the face, and inside the nose and mouth for any signs of bleeding or foreign objects.
2. Assess the trachea; is it midline? Is there jugular venous distension (JVD)? Check the back of the neck for point tenderness. Apply a rigid cervical immobilization device.

20. The Rapid Trauma Assessment
Steps of the rapid trauma assessment
Chest
Look
Listen
Feel
The EMT should assess the chest using a look, listen, and feel approach.
Expose the chest and assess the quality of breathing. Assess for paradoxical motion.
Auscultate the lungs.
Palpate and look for DCAP-BTLS. Palpate for crepitus.

21. The Rapid Trauma Assessment
Steps of the rapid trauma assessment
Extremities
Significant bleeding can accompany a broken bone
Assess using DCAP-BTLS
Major arteries, veins, and nerves run parallel to the large bones of the body. Therefore, if a large bone breaks, it is very likely that the sharp broken ends will puncture the vessels or damage the nerves, and bleeding can be significant. One of the objectives of an extremity check is to determine whether there is severe bleeding within the tissues.
Assess each extremity using DCAP-BTLS. Check pulse, motor, and sensation in all extremities .

22. The Rapid Trauma Assessment
Steps of the rapid trauma assessment
Back and buttocks
Check using DCAP-BTLS
Carefully control the spine
When the patient is being logrolled onto a backboard, a moment should be taken to assess the back and buttocks. Check for DCAP-BTLS. After a visual inspection for signs of injury, a hand should be run down the length of the spine from the top of the shoulders to the top of the buttocks. Any wounds or tenderness should be noted and reported.
Careful control of the spine using a rigid cervical immobilization device and continuous manual in-line stabilization is required. It takes a minimum of three providers to properly logroll the patient and assess the back and buttocks.

23. The Rapid Trauma Assessment

24. The Rapid Trauma Assessment
Steps of the rapid trauma assessment
Baseline vital signs and SAMPLE history
A baseline set of vital signs is a part of every physical assessment
A SAMPLE history is then performed
It is important to obtain a baseline set of vital signs. Once the rapid assessment is complete, the EMT must take the time to obtain as complete a SAMPLE history as possible. Frequently this history is taken while en route to the hospital.

25. The Rapid Trauma Assessment
With isolated injury, rapid trauma assessment may not be necessary
Focus on the injured part
If the injury is obviously isolated and the mechanism does not suggest further injury potential, it is not necessary to perform a head-to-toe rapid trauma assessment. If the mechanism of injury is minor or the injury is isolated, it is more appropriate to focus on the injured part.
Not every trauma call is a life or death emergency. In fact, most are not. This means that the nature of the injury permits the EMT to assess and stabilize it on scene. This assessment and stabilization before transport prevents further injury.
Activity: Divide the class into groups of four to five students and have them answer the questions in the case, “Ankle Injury.” Bring the class back together and have each group report on their responses.
Suggested Responses:
1. The potential for injury from this mechanism of injury is proportionate to the height of the fall. If the patient had fallen from the top of the escalator to the bottom, she could have been seriously injured. Fortunately, the patient fell at the bottom of the escalator and, without the added complication of entrapment, sustained only a minor trauma.
2. After completing the initial assessment, the EMT should proceed to a focused trauma examination while obtaining a SAMPLE history and baseline vital signs.
3. Barring any new information obtained after the assessment, it would be safe to assume that the patient has a minor injury and would be low priority.

26. The Rapid Trauma Assessment

27. The Rapid Trauma Assessment
An assessment limited to the area of injury
Performed in the same manner as the rapid trauma assessment
After an appropriate scene size-up and initial assessment reveal that the patient has no significant mechanism of injury or signs of serious injury, the EMT should begin a focused trauma assessment. A focused trauma assessment is a physical assessment that is limited to the area of injury. Except for the fact that it is limited to one body part or region, it is performed in the same manner as the rapid trauma assessment.

28. The Focused Trauma Assessment
Watch this video clip that demonstrates a focused assessment

29. Stop and Review Describe each component of DCAP-BTLS.
Describe the rapid trauma assessment by body regions.
Deformity, contusion, abrasion, puncture, burn, tenderness, laceration, swelling
Head and neck, chest, abdomen, extremities, back and buttocks