Assessment and Initial Management of the Trauma Patient

International Trauma Life Support, 6e
Key Lecture Points The concept of simultaneous assessment (team leader) and delegated intervention (team members) in life-threatening emergencies needs to be stressed. Point out that the Initial Assessment is interrupted only for airway obstruction, the scene becomes too dangerous, or the need to perform CPR. The step-by-step assessment scheme must be taught. Emphasize the need to get the critically injured patient out of the field and to an appropriate hospital as quickly as possible. The 10-minute rule must be reinforced. Stress that the Ongoing Exam should be repeated any time the patient’s condition worsens. Chapter 2 Assessment and Initial Management of the Trauma Patient

Assessment and Initial Management of the Trauma Patient
NOTE: Additional useful information can be found in: Appendix B: Communications with the Receiving Hospital Appendix C: Documentation: The Patient Care Record Appendix F: Trauma Scoring in the Prehospital Care Setting Appendix I: Multicasualty Incidents and Triage NOTE: Remember ITLS Primary Assessment and ITLS Secondary Assessment are taught in skill stations. Courtesy of ITLS Ontario

Overview Steps of ITLS Patient Assessment
ITLS Primary Survey ITLS Secondary Survey ITLS Ongoing Exam Initial Assessment related to Rapid Trauma Survey or Focused Exam Initial Assessment interruptions Critical conditions and critical interventions Patient Assessment -

ITLS Patient Assessment
ITLS Primary Survey Scene Size-up Initial Assessment Rapid Trauma Survey or Focused Exam ITLS Secondary Survey ITLS Ongoing Exam IMAGE: Figure 2-1: ITLS Patient Assessment (on page 30) NOTE: Use flowchart miniature to conceptualize and demonstrate how parts of Assessment fit together. You begin in same place for all patients, decision takes you on different paths, but come back to same for all patients. (Students do not need to be able to read flowchart on screen.) Flowchart is on page 30. NOTE: (US) ITLS patient assessment (Primary Survey, Secondary Survey, and Ongoing Exam) is consistent with U.S. Department of Transportation guidelines. FLOWCHART: (Top box—STEP for all patients) ITLS Primary Survey starts with Scene Size-up. If scene is safe to enter, moves on to next STEP. (Second box—STEP for all patients) Initial Assessment is VERY BRIEF exam of level of consciousness and ABCs, moves to next STEP. (Top diamond—DECISION splits group) Mechanism of Injury DECISION and information obtained in first two steps, go one of two directions and perform either Rapid Trauma Survey or Focused Exam. (Left branch—STEP) Rapid Trauma Survey is RAPID head-to-toe exam to determine if immediately life-threatening conditions exist and to identify those patients who should have immediate transport. (Right branch—STEP) Focused Exam is limited to area of injury. (Both branches come back to center diamond for DECISION) Based on situation: DECISION to perform or not perform ITLS Secondary Survey step. DECISION to perform or not perform ITLS Ongoing Exam step. (Bottom left box—STEP) ITLS Secondary Survey in that Secondary Survey is an evaluation for all injuries, not just life-threatening ones. (Bottom right box—STEP) ITLS Ongoing Exam is meant to identify changes in patient’s condition. ITLS Secondary Survey and ITLS Ongoing Exam steps can be performed as needed. Patient Assessment -

ITLS Primary Survey ITLS Primary Survey Scene Size-up Initial Assessment Rapid Trauma Survey or Focused Exam IMAGE: Figure 2-4: ITLS Primary Survey (on page 35) Patient Assessment -

Scene Size-up IMAGE: CALLOUT from ITLS Primary Survey (Figure 2-4 on page 35). NOTE: Use miniature to conceptualize and demonstrate how survey is a series of steps to be done in sequence without deviation. (Students do not need to be able to read steps on screen.) NOTE: The next series of slides steps through Rapid Trauma Survey. Remember: this skill will be taught in skill stations. Rapid Trauma Survey is a brief exam done to find all life-threats. Patient Assessment -

Scene Size-up NOTE: Scene Size-up has already been discussed; will not repeat details here. It cannot be stressed too much that failure to perform preliminary actions can jeopardize lives . Perform Scene Size-up as described in Chapter 1. If there are more patients than your team can effectively handle, triage them rapidly utilizing Triage Decision Tree and initiate MCI protocols. (See Chapter 1 and Appendix I.) (NOTE: See Appendix I, Multicasualty Incidents and Triage.) The Scene Size-up will set stage for how you will perform rest of ITLS Primary Survey. Patient Assessment -

Initial Assessment IMAGE: CALLOUT from ITLS Primary Survey (Figure 2-4 on page 35). NOTE: Use miniature to conceptualize and demonstrate how survey is a series of steps to be done in sequence without deviation. (Students do not need to be able to read steps on screen.) NOTE: The next series of slides steps through Rapid Trauma Survey. Remember: this skill will be taught in skill stations. Rapid Trauma Survey is a brief exam done to find all life-threats. Patient Assessment -

ITLS Primary Survey Initial Assessment Prioritizes patient
General impression Initial level of consciousness Manual stabilization of cervical spine ABCs Prioritizes patient Determines existence of immediately life-threatening conditions Once scene is safe to enter, team leader must focus on rapid assessment. All decisions on treatment require that you have identified life-threatening conditions. If immediate interventions are needed, delegate them to your team members while you continue assessment. Experience has shown that most mistakes occur because team leader stops to perform an intervention and forgets to perform part of assessment. Team approach makes most efficient use of time and allows you to rapidly perform Initial Assessment without performing noninvasive airway interventions yourself, which can interrupt your thought process. Purpose of Initial Assessment is to prioritize and determine existence of immediately life-threatening conditions. Information gathered is used to make decisions about critical interventions and time of transport. Initial Assessment is made up of general impression upon approaching patient, an evaluation of level of consciousness (LOC), manual stabilization of cervical spine (if needed), and assessment of airway, breathing, and circulation (ABCs). Patient Assessment -

ITLS Primary Survey Scene danger Airway obstruction Cardiac arrest
Less than 2 minutes Initial Assessment and Rapid Trauma Survey Delegate any intervention. Interrupt survey only for: Scene danger Airway obstruction Cardiac arrest Initial Assessment and Rapid Trauma Survey combined should take less than 2 minutes. Remember, once you begin ITLS Primary Survey, only 3 things should cause you to interrupt completion of assessment: Scene becomes unsafe. Must treat an airway obstruction. Must treat cardiac arrest. All other problems (such as respiratory arrest or dyspnea) may be addressed by team members. Stopping during survey causes you to overlook essential items. For critical patients, goal should be to have on-scene times of 5 minutes or less. While interventions may be important, only thing proven to increase survival of trauma patients is decreasing time to definitive care (trauma center). Patient Assessment -

ITLS Primary Survey General impression
Approximate age, sex, weight General appearance Position of patient body and surroundings Patient activity Obvious major injuries or bleeding Triage patients rapidly, if necessary. On approach, note patient’s approximate age, sex, weight, and general appearance. Old and very young are at increased risk. Female patients may be pregnant. Observe position of patient. Body position and position in relation to surroundings Note activity. (Is patient aware of surroundings, anxious, obviously in distress, etc.?) Any obvious major injuries or major bleeding? Observation of patient in relation to scene and mechanism of injury will help you prioritize. If there are multiple patients, rapidly triage them and begin evaluation of most seriously injured patient first. Patient Assessment -

ITLS Primary Survey U P V A Alert Unresponsive
Initial Level of Consciousness Cervical-spine stabilization Alert Responds to Verbal stimuli Responds to Pain Unresponsive U P V A Try to approach from front so patient does not try to turn head. Assessment begins immediately, even if patient is being extricated. As team leader, try to approach patient from front (face to face, so patient does not turn head to see you). If there is a mechanism of injury that suggests spinal injury, immediately and gently but firmly stabilize head and neck in a neutral position (this can be delegated to a team member). Stabilize head and neck in position found: If head or neck is held in an angulated position and patient complains of pain on any attempt to straighten it. If patient is unconscious and neck is held to one side and does not move when you gently attempt to straighten it. Speak to patient and ask a question such as, “Can you tell me what happened?” Reply gives immediate information about both airway and level of consciousness. If responds appropriately to questioning, you can assume that airway is open and level of consciousness (LOC) is normal. If response is not appropriate, make a mental note of LOC using AVPU scale. Anything below “A” (alert) should trigger a systematic search for causes during Rapid Trauma Survey. Patient Assessment -

ITLS Primary Survey Airway: look, listen, feel
Direct: simple positioning and suctioning If not adequate, not quickly correctable Interrupt: advanced airway techniques If cannot speak or is unconscious, further evaluation of airway should follow. Look, listen, and feel for movement of air. Position airway as needed. Avoid extending neck to open airway if trauma suspected. If airway obstructed (apnea, snoring, gurgling, stridor), use an appropriate method (reposition, sweep, suction) to open it immediately. Failure to quickly provide an open airway is one of three reasons to interrupt patient assessment part of ITLS Primary Survey. If simple positioning and suctioning fail to provide an adequate airway, or if stridor is present, advanced airway techniques may be necessary immediately. Patient Assessment -

ITLS Primary Survey Breathing: look, listen, feel If not adequate
Direct: high-flow oxygen If not adequate Direct: assisted ventilation Look, listen, and feel for movement of air. If unconscious, place your ear over patient’s mouth so you can judge both depth and rate of ventilations. Look at movement of chest (or abdomen), listen to sound of air movement, and feel both movement of air on your cheek and movement of chest wall with your hand. Notice if patient uses accessory muscles to breathe. If ventilation is inadequate (less than 8 per minute or too shallow), direct team member to assist ventilation immediately. Ensure adequate ventilatory rate and adequate volume. Monitor ventilation with capnography (recommended). EtCO2 at about 35 If breathing too fast, administer supplemental high-flow oxygen. As a general rule, all patients with multi-system trauma should receive supplemental high-flow oxygen. Patient Assessment -

Breathing Rates Normal Abnormal Adult 10–20 <10 and >24 Child 15–30 <15 and >35 Infant 25–50 <25 and >60 Patient Assessment -

ITLS Primary Survey Circulation: peripheral pulse Skin
No peripheral, check carotid Too fast, too slow, quality Interrupt: cardiac arrest Skin Color, temperature, condition Major bleeding scan Direct: bleeding control Note rate and quality of pulses at wrist (brachial in infant). Checking pulse in neck is not necessary if awake and alert or has a palpable peripheral pulse. Quickly note whether rate is too slow or too fast, and note quality (thready, bounding, weak, irregular). Remember, pulse rate is checking to determine how well blood is circulating and if sufficient for good perfusion. Is it too fast for good perfusion? (>120 in an adult) Is it too slow for good perfusion? (<60 in an adult) It is not a determination of tachycardia or bradycardia. If pulse absent at neck, immediately start CPR (unless there is massive blunt trauma) and prepare for immediate transport. One of three reasons to interrupt assessment during ITLS Primary Survey At wrist, note skin color, temperature, and condition (and capillary refill in an infant or small child). Pale, cool, clammy skin; thready radial pulse; and decreased LOC are best early assessments of decreased perfusion (shock). Direct control of bleeding. Patient Assessment -

MOI Decision Dangerous generalized or unconscious Dangerous focused
Rapid Trauma Survey Dangerous focused Focused Exam Not significant Initial Assessment normal If dangerous generalized mechanism of injury or if unconscious: Perform Initial Assessment and go directly to Rapid Trauma Survey. Perform interventions, transport, Ongoing Exams, and possibly a Secondary Survey en route. If dangerous focused mechanism of injury suggesting an isolated injury: Perform Initial Assessment and Focused Exam limited to area of injury. Full Rapid Trauma Survey is not required. Perform interventions, transport, Ongoing Exams, and possibly a Secondary Survey. If no significant life threat in mechanism of injury: Perform Initial Assessment and, if normal: Directly to a Focused Exam based on chief complaint. Secondary Survey would not be necessary. Patient Assessment -

Priority Patient Dangerous MOI History High-risk group
Loss of consciousness Difficulty breathing Severe pain in head, neck, torso High-risk group Altered mental status Difficulty breathing Abnormal perfusion Abnormal Initial Assessment NOTE: High-risk group (such as very young, very old, chronically ill). NOTE: Notice important of breathing. Difficulty breathing appears in both groups. Load-and-go patients include: Dangerous mechanism of injury History that reveals: Loss of consciousness Difficulty breathing Severe pain of head, neck, or torso High-risk group (such as very young, very old, chronically ill) Altered mental status Abnormal perfusion Any abnormality revealed during Initial Assessment Patient Assessment -

Rapid Trauma Survey IMAGE: CALLOUT from ITLS Primary Survey (Figure 2-4 on page 35). NOTE: Use miniature to conceptualize and demonstrate how survey is a series of steps to be done in sequence without deviation. (Students do not need to be able to read steps on screen.) NOTE: The next series of slides steps through Rapid Trauma Survey. Remember: this skill will be taught in skill stations. Rapid Trauma Survey is a brief exam done to find all life-threats. Patient Assessment -

Rapid Trauma Survey Inspect Head and Neck Major Facial Injuries, Bruising, Swelling, Penetrations, Subcutaneous Emphysema Neck Vein Distention? Tracheal Deviation? NOTE: This series of slides steps through Rapid Trauma Survey. (Colors are reversed to match Figure 2-4 on page 35.) NOTE: Remember: this skill will be taught in detail in skill stations. Inspect head and neck (look and feel) Major facial injuries, bruising, swelling, penetrations, subcutaneous emphysema Neck vein distention? Tracheal deviation? Assessment of neck is a continuation of breathing and circulation by checking for JVD, tracheal deviation, and subcutaneous emphysema. A rigid cervical extrication collar may be applied at this time. NOTE: If team leader elected to stabilize neck, this duty should be transferred to another rescuer at this time. Patient Assessment -

Rapid Trauma Survey Inspect Chest Asymmetry, Contusion, Penetrations, Paradoxical Motion, Instability, Crepitation Breath Sounds Present? Equal? (If unequal: Percussion) Heart Tones NOTE: This series of slides steps through Rapid Trauma Survey. (Colors are reversed to match Figure 2-4 on page 35.) NOTE: Remember: this skill will be taught in detail in skill stations. Inspect chest—expose and look, feel, and listen Asymmetry, contusion, penetrations, paradoxical motion, instability, crepitation Note if ribs rise with respiration or if there is only diaphragmatic breathing. Look for signs of blunt trauma or open wounds. Feel for tenderness, instability, and crepitation (TIC). Breath sounds —listen Present? Equal? Listen with stethoscope over lateral chest about fourth intercostal space in midaxillary line on both sides. If unequal: percussion If breath sounds are not equal (decreased or absent on one side), percuss chest to determine whether patient is just splinting from pain or if a pneumothorax or a hemothorax is present. Heart tones Very briefly notice heart sounds so you will have a baseline for changes such as development of muffled heart sounds. If abnormalities are found during chest exam (open chest wound, flail chest, tension pneumothorax, hemothorax), delegate appropriate intervention (seal open wound, stabilize flail, decompress severe tension pneumothorax). Patient Assessment -

Rapid Trauma Survey Abdomen Bruising, Penetration/Evisceration, Tenderness, Rigidity, Distention Pelvis Tenderness, Instability, Crepitation NOTE: This series of slides steps through Rapid Trauma Survey. (Colors are reversed to match Figure 2-4 on page 35.) NOTE: Remember: this skill will be taught in detail in skill stations. Abdomen Expose and look: bruising, penetration/evisceration Gently palpate: tenderness, rigidity, distention Pelvis Tenderness, instability, crepitation Look for deformity or penetrating wounds. Feel for tenderness, instability, and crepitation by gently pressing down on symphysis and gently squeezing in on iliac crests. Note that tenderness is not same thing as being unstable. The pelvis may be tender and yet stable. If pelvis is unstable, you can feel pelvic ring collapse as you apply pressure. If pelvis is unstable, do not check again! Lower/upper extremities Swelling, deformity, instability, motor, sensory Assess both upper legs, looking for deformity and feeling for TIC. Remember that bilateral femur fractures can produce enough internal blood loss to be life threatening. Scan for obvious wounds or deformities of arms and lower legs. Note whether patient can move fingers and toes before transferring to backboard. Place patient on backboard. Transfer patient to a long backboard, checking posterior of patient as you do this. If patient has an unstable pelvis or bilateral femur fractures, to prevent further injuries, use a scoop stretcher (Figure 2-5) to transfer patient to a long backboard. Patient Assessment -

Rapid Trauma Survey Lower/Upper Extremities Swelling, Deformity, Instability, Motor, Sensory Place Patient on Backboard Posterior Penetrations, Deformity, Presacral Edema NOTE: This series of slides steps through Rapid Trauma Survey. (Colors are reversed to match Figure 2-4 on page 35.) NOTE: Remember: this skill will be taught in detail in skill stations. Lower/upper extremities Swelling, deformity, instability, motor, sensory Assess both upper legs, looking for deformity and feeling for TIC. Remember that bilateral femur fractures can produce enough internal blood loss to be life threatening. Scan for obvious wounds or deformities of arms and lower legs. Note whether patient can move fingers and toes before transferring to backboard. Place patient on backboard. Transfer patient to a long backboard, checking posterior of patient as you do this. If patient has an unstable pelvis or bilateral femur fractures, to prevent further injuries, use a scoop stretcher (Figure 2-5) to transfer patient to a long backboard. Patient Assessment -

Rapid Trauma Survey If critical situation, transfer to ambulance to complete exam. NOTE: This series of slides steps through Rapid Trauma Survey. (Colors are reversed to match Figure 2-4 on page 35.) NOTE: Remember: this skill will be taught in detail in skill stations. Patient Assessment -

Rapid Trauma Survey Baseline Vital Signs Measured Pulse, Respirations, Blood Pressure Pupils Size? Reactive? Equal? (If Altered Mental Status:) Glasgow Coma Scale Score Eyes, Voice, Motor, Orientation, Emotional State NOTE: This series of slides steps through Rapid Trauma Survey. (Colors are reversed to match Figure 2-4 on page 35.) NOTE: Remember: this skill will be taught in detail in skill stations. Baseline vital signs Measured pulse, respirations, blood pressure Obtain baseline vital signs and rest of SAMPLE history. Vital signs and SAMPLE should be done during transport for critical patients. Pupils Size? Reactive? Equal? If altered mental status: Brief neurological exam Identify possible increased intracranial pressure (ICP) Includes pupils, Glasgow Coma Scale (GCS) score, and signs of cerebral herniation. Always performed during transport. Finger-stick glucose performed at beginning of transport. Glasgow Coma Scale Score Eyes, voice, motor, orientation, emotional state Look for medical identification devices. Consider nontraumatic causes of altered mental status. Patient Assessment -

Glasgow Coma Scale IMAGE: Table 2-4: Glasgow Coma Scale Score (on page 40) NOTE: Also referred to either as Glasgow Coma Scale or Glasgow Coma Score. Very important to do this as a base line; how it changes is of critical importance. It is done at END of Rapid Trauma Survey (if altered mental status). It is done early in Secondary Survey. *Decorticate posturing to pain **Decerebrate posturing to pain Patient Assessment -

Brief Targeted History
S Symptoms A Allergies M Medications P Past medical history L Last oral intake E Events preceding incident At same time as you are performing patient assessment part of ITLS Primary Survey, you or a team member obtain a brief target history (including SAMPLE history) from patient and from bystanders. A more detailed history may be taken later during ITLS Secondary Survey. Especially important: If information must be gathered from bystanders, since they will not be available to question once transport is initiated. If patient has loss of consciousness during transport. Patient Assessment -

Load-and-Go Situations
International Trauma Life Support, 6e Load-and-Go Situations Initial Assessment Altered mental status Abnormal respiration Abnormal circulation Shock potential Abnormal chest exam Tender, distended abdomen Pelvic instability Bilateral femur fractures NOTE: Significant mechanism of injury and/or poor general health has been added to “Load and Go” criteria. Upon completion of Initial Assessment and Rapid Trauma Survey or Focused Exam, enough information is available to decide if a critical situation is present. Patients with critical trauma situations are transported immediately. Most treatment interventions will be done during transport. If any of following critical injuries or conditions exist, transport immediately. Initial Assessment reveals: Altered mental status Abnormal respiration Abnormal circulation (shock or uncontrolled bleeding) Signs discovered during Rapid Trauma Survey of conditions that rapidly lead to shock: Abnormal chest exam (flail chest, open wound, tension pneumothorax, hemothorax) Tender, distended abdomen Pelvic instability Bilateral femur fractures Significant mechanism of injury and/or poor general health of patient: As you consider mechanisms, age, general appearance, chronic illnesses, and so on, you may decide that patient is at higher risk than ITLS Primary Survey alone would suggest. These higher-risk patients should go to a trauma center even though they might not meet other criteria to go there. Remember that there are more considerations than just physical exam of patient. Significant MOI and/or poor general health Patient Assessment -

When in doubt—transport early! Patient Assessment -

Critical Interventions
On-scene procedures Manage airway Assist ventilation Administer oxygen Begin CPR Control major external bleeding Seal sucking chest Stabilize flail chest Decompress tension pneumothorax Stabilize impaled Complete packaging NOTE: These will be discussed in other lectures. Do not spend time teaching techniques now. Emphasize that only procedures done on scene directly relate to components of ITLS Primary Survey. These procedures are done at scene, and most of them can be delegated to team members to perform while you continue ITLS Primary Survey. Patient may be in a state of compensated shock; anticipate needs. Patient Assessment -

Initiate Transport Procedures not on scene, not life-saving
Splinting, bandaging, IV line insertion Endotracheal intubation, often Contact medical direction As early as possible Estimated time of arrival (ETA) Condition of patient Special needs on arrival Procedures that are not life saving, such as splinting, bandaging, insertion of IV lines, or even emergency endotracheal intubation, must not hold up transport of critical patient. If BVM ventilation is sufficient to transfer to ambulance and initiate transport, perform endotracheal intubation in transit. At this point, ITLS Primary Survey is over and team leader may help other rescuers with patient care. It is extremely important to contact medical direction as early as possible with critical patients. It takes time to get appropriate surgeon and operating room team in place, and critical patient has no time to wait. Always notify receiving facility of your estimated time of arrival (ETA), condition of patient, and any special needs on arrival. (NOTE: See Appendix B: Communications with the Receiving Hospital.) Patient Assessment -

ITLS Secondary Survey IMAGE: Figure 2-6: ITLS Secondary Survey (on page 39). NOTE: Use miniature to conceptualize and demonstrate how survey is a series of steps to be done in sequence without deviation. (Students do not need to be able to read steps on screen.) NOTE: The next series of slides steps through Rapid Trauma Survey. Remember: this skill will be taught in skill stations. Rapid Trauma Survey is a brief exam done to find all life-threats. Patient Assessment -

ITLS Secondary Survey More comprehensive exam Performed
Evaluation for all injuries, not just life-threatening Establishes baseline for treatment decisions Performed Critical patients—done during transport Short transport—may not have time Non-critical patients—done on scene NOTE: ITLS Secondary Survey is taught in skill station. ITLS Secondary Survey More comprehensive exam to identify all injuries, not just life-threatening. Establishes baseline from which treatment decisions will eventually be made. Important to record information discovered. Whether or not to perform a Secondary Survey as well as when to perform one depends on situation. Critical patients should have this assessment done during transport rather than on scene. Although we say Secondary Survey should be done on critical patients during transport, we have to apply a little common sense. More accurately, we should say “do not delay scene time of a critical patient.” If you are unable to transport, e.g., are waiting for an ambulance/helicopter or patient is being extricated, a Secondary Survey may be performed on scene. If there is a short transport and you must perform interventions, you may not have time to do Secondary Survey. If Primary Survey does not reveal a critical condition, Secondary Survey may be performed on scene. Transport immediately if ITLS Secondary Survey reveals development of any critical trauma situations. Patient Assessment -

ITLS Secondary Survey Initial Assessment Repeat routinely Vital signs Monitoring Detailed Exam Head-to-toe DCAP-BTLS IMAGE: Figure 2-6: ITLS Secondary Survey (on page 39). NOTE: ITLS Secondary Survey is taught in skill station. NOTE: Overview of next slides. Although we say Secondary Survey should be done on critical patients during transport, we have to apply a little common sense. More accurately, we should say “do not delay scene time of a critical patient.” If you are unable to transport, e.g., are waiting for an ambulance/helicopter or patient is being extricated, a Secondary Survey may be performed on scene. Patient Assessment -

ITLS Secondary Survey Initial Assessment LOC AVPU Airway Control Cervical Spine Snoring, Gurgling, Stridor, Silence Breathing Present? Rate, Depth, Effort Carotid/Radial Pulses Present? Rate, Rhythm, Quality Skin Color, Temperature, Moisture; Capillary Refill Uncontrolled External Hemorrhage? NOTE: Information is portrayed just as on Figure 2-6: ITLS Secondary Survey (on page 39). NOTE: Prior to teaching this lecture, determine level of detail to be covered in lecture compared to skill station. NOTE: Initial Assessment was covered earlier in this lecture, so this should be reviewed, not taught again. However, it is repeated in lecture to reinforce to students that they need to repeat it with trauma patients. Initial Assessment—repeat routinely LOC: AVPU Airway: Control cervical spine (snoring, gurgling, stridor, silence) Breathing: Present? Rate, depth, effort Carotid/radial oulses: Present? Rate, rhythm, quality Skin color, temperature, moisture; capillary refill Uncontrolled external hemorrhage? Patient Assessment -

Detailed Exam: DCAP-BTLS
International Trauma Life Support, 6e Detailed Exam: DCAP-BTLS Deformities Contusions Abrasions Penetrations Burns Tenderness Lacerations Swelling Patient Assessment -

ITLS Secondary Survey DETAILED EXAM Patient History Complete SAMPLE History Vital Signs Measured Pulse, Respirations, Blood Pressure SpO2, ECG, Blood Sugar, EtCO2 Glasgow Coma Scale Score Eyes, Voice, Movement; Emotional State Head Pupils, Battle’s Sign, Raccoon Eyes, Drainage; DCAP-BTLS NOTE: This series of slides steps through Detailed Exam. (Colors are reversed to match figure.) NOTE: DCAP-BTLS = deformities, contusions, abrasions, penetrations, burns, tenderness, lacerations, or swelling NOTE: SpO2 = pulse oximetry EtCO2 = end-tidal carbon dioxide monitoring DETAILED EXAM of complaints and previously found injuries Exam consists of inspection, auscultation, palpation, and sometimes percussion. Patient history—info not obtained in Primary Complete SAMPLE history Vital signs—repeat routinely Measured pulse, respirations, blood pressure Pulse oximeter (SpO2), cardiac monitor (ECG), blood sugar, CO2 monitor (EtCO2) Glasgow Coma Scale Score Eyes, voice, movement; emotional state Head Pupils, Battle’s sign, raccoon eyes, drainage; deformities, contusions, abrasions, penetrations, burns, tenderness, lacerations, swelling (DCAP-BTLS) Neck DCAP-BTLS; neck vein distention? Tracheal deviation? Chest Asymmetry; paradoxical motion; DCAP-BTLS; tenderness, instability, crepitation (TIC) Breath sounds Present? Equal? If unequal: percussion Heart tones abdomen DCAP-BTLS; rigidity, distention Pelvis DCAP-BTLS Lower/upper extremities DCAP-BTLS; TIC; PMS Posterior Examine only if not done in ITLS Primary Survey (DCAP-BTLS) At conclusion, finish bandaging and splinting. Patient Assessment -

ITLS Secondary Survey Neck DCAP-BTLS; Neck Vein Distention? Tracheal Deviation? Chest Asymmetry; Paradoxical Motion; DCAP-BTLS; Tenderness, Instability, Crepitation [TIC] Breath Sounds Present? Equal? (If unequal: Percussion) Heart Tones NOTE: This series of slides steps through Detailed Exam. (Colors are reversed to match figure.) NOTE: DCAP-BTLS = deformities, contusions, abrasions, penetrations, burns, tenderness, lacerations, or swelling NOTE: SpO2 = pulse oximetry EtCO2 = end-tidal carbon dioxide monitoring DETAILED EXAM of complaints and previously found injuries Exam consists of inspection, auscultation, palpation, and sometimes percussion. Patient history—info not obtained in Primary Complete SAMPLE history Vital signs—repeat routinely Measured pulse, respirations, blood pressure Pulse oximeter (SpO2), cardiac monitor (ECG), blood sugar, CO2 monitor (EtCO2) Glasgow Coma Scale Score Eyes, voice, movement; emotional state Head Pupils, Battle’s sign, raccoon eyes, drainage; deformities, contusions, abrasions, penetrations, burns, tenderness, lacerations, swelling (DCAP-BTLS) Neck DCAP-BTLS; neck vein distention? Tracheal deviation? Chest Asymmetry; paradoxical motion; DCAP-BTLS; tenderness, instability, crepitation TIC Breath sounds Present? Equal? If unequal: percussion Heart tones abdomen DCAP-BTLS; rigidity, distention Pelvis DCAP-BTLS Lower/upper extremities DCAP-BTLS; TIC; PMS Posterior Examine only if not done in ITLS Primary Survey (DCAP-BTLS). At conclusion, finish bandaging and splinting. Patient Assessment -

ITLS Secondary Survey Abdomen DCAP-BTLS; Rigidity, Distention Pelvis DCAP-BTLS Lower/Upper Extremities DCAP-BTLS; TIC; PMS Posterior Examine only if not done in ITLS Primary Survey DCAP-BTLS NOTE: This series of slides step through Detailed Exam. (Colors are reversed to match Figure.) NOTE: DCAP-BTLS = deformities, contusions, abrasions, penetrations, burns, tenderness, lacerations, or swelling. NOTE: Stress importance of abdominal exam. DETAILED EXAM of complaints and previously found injuries Exam consists of inspection, auscultation, palpation, and sometimes percussion. Patient history—info not obtained in Primary Complete SAMPLE history Vital signs—repeat routinely Measured pulse, respirations, blood pressure Pulse oximeter (SpO2), cardiac monitor (ECG), blood sugar, CO2 monitor (EtCO2) Glasgow Coma Scale Score Eyes, voice, movement; emotional state Head Pupils, Battle’s sign, raccoon eyes, drainage; deformities, contusions, abrasions, penetrations, burns, tenderness, lacerations, swelling (DCAP-BTLS) Neck DCAP-BTLS; neck vein distention? Tracheal deviation? Chest Asymmetry; paradoxical motion; DCAP-BTLS; tenderness, instability, crepitation TIC Breath sounds Present? Equal? If unequal: percussion Heart tones abdomen DCAP-BTLS; rigidity, distention Pelvis DCAP-BTLS Lower/upper extremities DCAP-BTLS; TIC; PMS Posterior Examine only if not done in ITLS Primary Survey (DCAP-BTLS). At conclusion, finish bandaging and splinting. Patient Assessment -

ITLS Ongoing Exam Change in condition Perform and record Patient
Interventions Perform and record Critical: every 5 minutes Stable: every 15 minutes Each time patient moved With each intervention If condition worsens IMAGE: Figure 2-1: ITLS Patient Assessment (on page 30). Ongoing assessment and management includes critical procedures performed on scene and during transport and communication with medical direction. Ongoing Exam is abbreviated exam to assess for changes in condition. Concentrate on reassessing only those things that may change. In contrast to ITLS Secondary Survey, which is performed only once, Ongoing Exam may be performed multiple times during a long transport. Patient Assessment -

ITLS Ongoing Exam Subjective Changes “How do you feel? Reassess Mental Status LOC, Pupils, GCS Reassess ABCs Patency, Vital Signs, Color, Skin Condition, Temperature, JVD, Tracheal Deviation, Breath Sounds, Heart Tones Reassess Abdomen Development of Tenderness, Distention, Rigidity Check Each Identified Injury Change in Status, PMS Check Interventions Patency, Position, Flow Rate, Security Patient Assessment -

Summary ITLS Patient Assessment Remain calm Key to trauma care
Not difficult, but time-critical Rapid, orderly, thorough Remain calm Optimum speed by organization and teamwork Patient Assessment -

Discussion Patient Assessment -

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