Assessment and Initial
Management of the
Trauma Patient
1
INTRODUCTION
• Rapid systematic assessment is
key
• Interventions identified as
lifesaving measures are
initiated immediately
• A-B-C’s first step in initial
assessment 2
SCENE
SIZE-UP
COURTESY OF BONNIE MENEELY, R.N.
3
SCENE
SAFETY/ SECURITY
• Medic situational assessment differs
from civilian scene size-up.
• Centers around an awareness of the
tactical situation and current hostilities.
• Examine Battlefield:
– Determine zones of fire
– Routes of access and egress
– Casualties occur over time changing
demands 4
CARE UNDER FIRE
• What care can be offered at
casualty’s side
• Effects of movement, noise,
and light
• Movement to safety
• Cover and Concealment
5
ENTERING A FIRE
ZONE
• Seek cover and concealment
• Survey for small arms fire
• Detect for fire or explosives
• Determine NBC status
• Survey structures for stability
6
MOVING CASUALTY TO SAFE
AREA FOR TREATMENT
• Low profile for casualty and yourself
• May need to request assistance
• Protection outweighs risk of aggravating
injuries
• NEVER hesitate to move a casualty
who is under fire.
• If casualty is not under fire, you may
elect to delay movement if C-spine
injury likely. 7
MECHANISM OF
INJURY
• Determine how injury occurred
– Burns
– Ballistics
– Falls
– NBC
– Blast
8
NUMBER OF PATIENTS
• Consider Mass casualty
situation
• Triage patients accordingly
• Need for assistance or
additional supplies
• Manage time, equipment, and
resources 9
ADDITIONAL HELP
• Direct Combat Lifesavers
(CLS) to provide treatment
• Direct self-aid/buddy aid
• Request of suppressive fire
for movement of casualties
• Plan evacuation routes
10
C-SPINE STABILIZATION/
OTHER EQUIPMENT
• Spineboard
• C-collar
• Factors or Limitations of NBC
environment
• Other equipment:
– Airway adjuncts
– Oxygen
– Extrication devices
11
ASSESSMENT AND INITIAL
MANAGEMENT OF THE
TRAUMA PATIENT
12
BTLS PRIMARY
SURVEY
• Scene Size-up
• Initial Assessment
• Rapid Trauma Survey
or Focused Exam
13
PURPOSES OF INITIAL
ASSESSMENT
• Prioritize casualties
• Determine immediate life threatening
conditions
• Information gathered used to make
decisions concerning critical
interventions and time of transport
• No secondary interventions
implemented before completion of
initial assessment
14
NO SECONDARY
INTERVENTIONS WILL BE
IMPLEMENTED BEFORE
COMPLETION OF INITIAL
ASSESSMENT EXCEPT FOR:
• Airway Obstruction
• Cardiac Arrest
15
FORM GENERAL
IMPRESSION
• Observe position of casualty
– posture
– accessibility
• Appearance of casualty
• Begin to establish priorities of
care
16
ESTABLISH C-SPINE CONTROL
AT THIS TIME
17
LEVELS OF
CONSCIOUSNESS
A – ALERT AND ORIENTED
V – RESPONDS TO VERBAL
STIMULI
P – RESPONDS TO PAIN
U – UNRESPONSIVE (NO
COUGH OR GAG REFLEX) 18
ASSESS AIRWAY
If patient is unable to speak or
is unconscious then evaluate
further
19
OPENING THE
AIRWAY
Modified Jaw
Thrust
20
OBSTRUCTED AIRWAY
• Attempt to ventilate; if
unsuccessful
• Reposition and attempt to
ventilate again
• Visualize observing for obvious
obstruction
• Suction, if needed
21
OBSTRUCTED AIRWAY
con’t
• Consider FBAO management
• Consider Combi-tube
• Consider Needle Cricothroidotomy
22
RATE AND QUALITY OF
RESPIRATIONS
• Absent - Ventilate twice and check
pulse and do CPR if required. Then
provide PPV at 12-15 resp/min with
15L/m of O2
• Rate<12/min - BVM at 12-15/min with
15L/m of O2
• Low Tidal Volume - BVM at 12-15/min
with 15L/m of O2
23
RATE AND QUALITY OF
RESPIRATIONS
• Labored - Oxygen by non-rebreather at
15L/min
• Normal or Rapid - All trauma patients
should receive oxygen
• Ventilation rate is 12-15/min instead of
10-12 IAW AHA due to the patient being
without oxygen for a probable extended
period of time. The increase in
ventilation rate also allows for mask
leak which can average up to 40%. 24
ACTIONS FOR SPECIFIC
AIRWAY SOUNDS
• Snoring - Jaw Thrust
• Gurgling - Suction
• Stridor – consider Combi-tube
• Silence - Follow steps in
assessing airway
25
Assess Circulation
26
Assess Circulation
• Palpate carotid and radial
pulses; brachial in an infant
• Check CCT
• Check for major bleeding
27
RADIAL PULSE
• Present - Note rate and quality
• Bradycardia - Consider spinal
shock; head injury
• Tachycardia - Consider shock
• Absent - Check carotid pulse;
note late shock (consider
PASG)
28
CAROTID PULSE
• Present - Note rate and quality
• Bradycardia (<60bpm) -
Consider spinal shock; head
injury
• Tachycardia (>120bpm) -
Consider shock
• Absent - CPR + BVM+O2,
Defib with AED as appropriate
29
CHECK FOR MAJOR
BLEEDING
• Direct pressure and
elevation
• Pressure dressing
• Pressure points
• Tourniquet
• PASG
30
CPR
• Combat situation CPR will be
METT-T dependent
• If METT-T allows, you would
begin CPR for the potentially
expectant patient
31
EXPOSE WOUNDS
• Remove all equipment and
clothing from area around
wounds
• Identify any additional life-
threatening injuries
32
DCAP-BLS
• Deformities • Burns
• Contusions • Lacerations
• Abrasions • Swelling
• Penetrations
33
Deformities
34
Contusions (bruises)
35
Abrasions
36
Punctures/Penetrations
37
Burns
38
Lacerations
39
Swelling
40
PALPATION
Touching or feeling for:
• TIC
• TRD-P
41
TIC
• Acronym used when palpating
body parts of the body
• TIC
– Tenderness
– Instability
– Crepitus
42
TRD-P
• Acronym used when palpating
the abdomen
• TRD-P
– Tenderness
– Rigidity
– Distention
– Pulsating Masses
43
RAPID TRAUMA SURVEY
! Head
Quick “Head-To- ! Neck
Toe” Exam ! Chest
! Abdomen
! Pelvis
! Extremities
! Back 44
RAPID TRAUMA SURVEY
• BRIEF exam done to find all
life-threats
• No splinting done except for
anatomically splinting casualty
to a spineboard
• Only a few interventions are
done on scene
45
INTERVENTIONS
PERFORMED AT SCENE
• Initial Airway Management
• Assist Ventilations
• Begin CPR if METT-T allows
• Control of major external
bleeding
46
INTERVENTIONS
PERFORMED AT SCENE
• Seal sucking chest wounds
• Stabilize flail chest
• Decompress tension
pneumothorax
• Stabilize impaled objects
47
HEAD
• DCAP-BLS
• Obvious
hemorrhage
• Major facial
injuries - consider
other airway
adjuncts
• TIC
48
NECK
• DCAP-BLS
• Retraction at suprasternal notch
• Tracheal deviation
• JVD
• Use of accessory muscles
• TIC
• Cervical spine step-off
49
AUSCULTATE FOR AIR
SOUNDS IN TRACHEA
• Stridor
• Gurgling
• Snoring
50
APPLY C-COLLAR AFTER
ASSESSING NECK
51
Chest: DCAP-BLS + TIC, paradoxical motion,
Symmetry, Breath Sounds (Presence and
Quality), and heart sounds (baseline
measurement)
52
Listen to both sides of the chest. Is air ent
present? Absent? Equal on both sides?
Compare left side to right side.
Mid-Clavicular Mid-Axillary
53
DIMINISHED OR ABSENT
BREATH SOUNDS
• Percuss to check for
hemothorax vs. pneumothorax
• Hypo-resonance = Hemothorax
• Hyper-resonance =
Pneumothorax
54
PNEUMOTHORAX OR
COLLAPSED LUNG
• Collection of air or gas in
pleural spaces
• Open chest wounds that permit
entrance of air
• May occur spontaneously
without apparent cause
55
OPEN PNEUMOTHORAX
56
TENSION PNUEMOTHORAX
• Required as consideration by any or all
of the following
– Decreased or absent breath sounds
– Decreasing LOC
– Absent radial pulse
– Cyanosis
– JVD
– Tracheal Deviation
– Decreasing bag compliance
57
TENSION PNEUMOTHORAX
58
INDICATIONS TO DECOMPRESS
TENSION PNEUMOTHORAX
The presence of tension
pneumothorax with
decompensation as evidenced by
more than one of the following:
– Respiratory distress and
cyanosis
– Loss of radial pulse (late shock)
– Decreasing LOC 59
ABDOMEN
• DCAP - BLS
• External blood loss
• Impaled objects
• Evisceration
• Inspect posterior
abdomen for exit
wounds/bruising
• Palpate for:
– TRD-P
60
PELVIS
• DCAP-BLS
• Priaprism
• Incontinence
• TIC
• Symphysis Pubis
• Iliac Crests
61
EXTREMITIES
• Examine lower then
upper extremities
• DCAP-BLS
• TIC
• PMS in each
extremity
62
LOGROLL AND PLACE ON
BACKBOARD UNLESS
CONTRAINDICATED
CONTRAINDICATIONS TO LOGROLL:
• Pelvic Instability
• Bilateral Femur Fractures
A Scoop Litter is required with these injuries
63
BACK
• Done DURING transfer to
backboard
• DCAP - BLS
• Rectal Bleeding
• TIC
64
SAMPLE HISTORY
• S – SIGNS/SYMPTOMS
• A – ALLERGIES
• M –MEDICATIONS
• P – PAST MEDICAL HISTORY
• L – LAST MEAL
• E – EVENTS PRIOR TO INJURY
65
OBTAIN BASELINE
VITALS
• Pulse
• Respirations
• Blood Pressure
• Pupils
• CCT
66
Neurological Exam
Perform brief exam if patient has an
altered mental status
• PERL
• Glasgow Coma Scale (GCS)
• Assess disability
67
TRANSPORT PATIENT
OR MOVE PATIENT TO
CASUALTY
COLLECTION POINT
68
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