Trauma Scenario - ITLS PDF

ITLS Scenario 1 - GSW with Dyspnea, Hemothorax, Extremity Injury
Scene Size Up
Transport Decision / Packaging / Notification
Standard Precautions
Gloves. Goggles.
Scene Hazards
None. The police have secured the scene.
Transport Decision
Unstable, load and go.
Number of Patients
One.
Packaging
Need for more help or

equipment
Police are on scene and can assist.
Check posterior during roll onto board.

No exit wound is found.
Notification
Mechanism of Injury
You have been called to the scene of a

murder / suicide. The male has injuries not
compatible with life. A female has also
been shot and the police lead you over to
her.
Notify hospital immediately. Notification

should include that you are en route with
the victim of a gunshot wound (GSW) to
the right anterior chest.
Ventilations are being assisted, the sucking
chest wound has been sealed, and the
patient also has a closed extremity fracture.
Initial Assessment
LOC (AVPU)
Alert.
General Impression
- Age, sex, position
- Patient activity
- Obvious Bleeding?
Pt. is found supine, conscious, with

obvious dyspnea. Pt. states I..
cant breathe. A large contusion is
noted on the patients forehead.
Airway
- Snoring? Gurgling?
Stridor? Silence?
Clear and open.
LOC (AVPU)
Alert.
Breathing
- Rate, Depth, Effort
Airway
Stridor? Silence?
Clear and open.
Breathing
Rapid, shallow, gasping respirations.

Direct team to assist ventilations.
Circulation
- Pulse rate / rhythm /
quality
- Skin color / cond /
temp
- Deadly bleeding?
Rapid, shallow, gasping respirations.

Continue assisting ventilations.
Direct team member to apply c-spine.
Delegate Spine
Rapid radial pulses present.

Cyanotic, cold, clammy.
Spot of blood visible on R anterior chest.
Circulation
quality
temp
Contusion on forehead.
No.
No.
No.
Neck
- DCAP-BLS-TIC
- Tracheal Deviation
- JVD
- Collar once checked
No obvious injury.
Midline.
Flat neck veins.
Direct team member to apply.
Chest
- Expose.
- DCAP-BLS-TIC
Expose chest. Sucking chest wound on

right anterior chest. Crepitus felt on right
side. Direct team member to seal.
Breath Sounds (2 points)
No breath sounds on right side.
Abdomen
- Expose.
- DCAP-BLS-TIC
- Rigidity or distention
Expose abdomen.
No injuries noted.
Soft, non-tender.
Pelvis (DCAP-BLS-TIC)
Stable.
Lower Extremities
- DCAP-BLS-TIC
- Distal PMS
No injuries noted.
Good distal PMS.
Upper Extremities
- DCAP-BLS-TIC
- Distal PMS
Deformity of left forearm. Stabilize.

Good distal PMS.
Rapid, weak radial pulses.

Cyanotic, cool, clammy.
Reassess Vital Signs
* In repeat ongoing assessments
Reassess Neck
No change.
Reassess Chest
No change.
Reassess Abdomen
No change.
Reassess interventions
Ensure ventilations still effective.
Secondary Survey
Rapid Trauma Survey

Head
- DCAP-BLS-TIC
- Fluid leaks (ears / nose)
- Raccoon Eyes
- Battles Signs
Ongoing Exam (every 5 minutes for unstable pt)
History
- Signs & Symptoms
- Allergies
- Medications
- Past Medical History
- Last Oral Intake
- Events
SOB.
Tetanus toxoid.
None.
None.
3 hours ago.
GSW as described above.
Vital Signs
- Blood pressure
- Heart rate / quality
- Resp rate / quality
- SPO2
- Capillary blood glucose
- LOC / GCS
- Skin
- Pupils
90/60
130, weak at radial.
36 and shallow if not assisted.
92% with O2 (if assisted).
N / A.
4/5/6 = 15.
Cyanotic, cool, clammy.
Both 5mm, equal and reactive.
Note: It is acceptable to initiate IV
access at this time.
Head to Toe
- Head
- Neck
- Chest
- Breath sounds
- Abdomen
- Pelvis
- Lower extremities
- Upper extremities
No injuries noted.
No injuries. No tracheal shift or JVD.
Sealed chest wound on right anterior chest
No breath sounds on right side.
Soft, non-tender.
No injuries noted.
No injuries noted. Good distal PMS.
Closed left forearm fracture. Good distal
PMS.
87
ITLS Scenario 2 - MVC, Pregnant Pt with Dislocated Hip, Fractured Pelvis, Chest Injury
y
Scene Size Up
Gloves. Goggles.
Scene Hazards
None. The vehicle is stable.
Transport Decision
Number of Patients
One.
Packaging

equipment
Extricate patient onto board. Ensure

posterior is checked during move.
Notification
Mechanism of Injury
The patient is an unrestrained pregnant

driver of a car that went off the road at
90kph and hit a tree head on. The patient
is still in the drivers seat. ** Simulate
vehicle in classroom with chairs.

should include that you have a conscious
pregnant female involved in a high speed
MVI, with chest, abdominal, hip and pelvic
injuries.
Initial Assessment
General Impression
- Patient activity
- Obvious bleeding?
Pt. is found sitting in the drivers seat of the

car, conscious, complaining that my hip
hurts so bad! My chest and stomach hurt
too. Im concerned about my baby! **
Simulate vehicle in classroom with
chairs.
LOC (AVPU)
Alert.
Delegate Spine
Airway
Stridor? Silence?
Clear and open.
Breathing
Normal rate and quality.

Direct team member to apply O2.
Circulation
quality
temp
- Deadly bleeding?

Normal, warm and dry.
No external bleeding.
Rapid Trauma Survey

Head
- DCAP-BLS-TIC
- Raccoon Eyes
- Battles Signs
No obvious injury.
No.
No.
No.
Neck
- DCAP-BLS-TIC
- JVD
No obvious injury.
Midline.
Flat neck veins.
Chest
- Expose.
- DCAP-BLS-TIC
Expose chest.
Contusion on sternum. Tender, no
instability.
Present and equal.
Abdomen
- Expose.
- DCAP-BLS-TIC
Expose abdomen.
Obvious late pregnancy.
Distended and tender.
Pain on palpation. Unstable.
Lower Extremities
- DCAP-BLS-TIC
- Distal PMS
Left leg flexed at hip and knee, internally

rotated. Right leg normal. Stabilize.
Good distal PMS.
Upper Extremities
- DCAP-BLS-TIC
- Distal PMS
No injuries detected.
Good distal PMS.
LOC
(AVPU)
Airway
Stridor? Silence?
Breathing
Circulation

quality
temp
Reassess
Neck
Reassess
Chest
Reassess
Abdomen
Reassess
interventions
Alert.
Clear and open.

Pale, cool, clammy. * Deterioration.
No change.
No change.
No change.
Ensure immobilization still effective.
Secondary Survey
History
- Signs & Symptoms
-
Allergies
Medications
Past Medical History
Last Oral Intake
Events
Vital Signs
- Blood pressure
- SPO2
- LOC / GCS
- Skin
- Pupils
My hip hurt so bad! My chest and

stomach too.
Penicillin.
Prenatal vitamins and Dilantin.
Epilepsy. 7 months pregnant.
5 hours ago.
I was driving down the road and woke up
like this. I think I had a seizure.
100/60.
24, shallow but effective.
98% with O2.
N / A.
4/5/6 = 15.
Pale, cool, clammy.
access at this time, and bolus if
required.
Head to Toe
- Head
- Neck
- Chest
- Breath sounds
- Abdomen
-
Pelvis
Lower extremities
Upper extremities
No injuries noted.
Sternal and anterior rib tenderness.
Breath sounds present and equal.
Distended. Pregnant. Increasing
tenderness.
Do not reexamine.
Unchanged from above. Good distal PMS.
No injuries note. Good distal PMS.
88
ITLS Scenario 3 - Motorcycle Rollover, Conscious Pt with Pelvis and Lower Extremity Injuries
ies
Scene Size Up
Gloves. Goggles.
Scene Hazards
None.
Transport Decision
Number of Patients
One.
Packaging

equipment
The police are on scene and can assist.
Direct member to strap legs together.

Ensure posterior is checked during
move.
Mechanism of Injury
The patient was thrown from a motorcycle

that crashed into a tree at high speed. The
rider was killed instantly, with obvious signs
of death. The patient was thrown into a
ditch.
Notification
Notify hospital immediately. Note that you

have a conscious patient with pelvis and
lower extremity injuries that was thrown off a
motorcycle at high speed. The accident also
included a fatality.
Initial Assessment
General Impression
- Patient activity
- Obvious Bleeding?
Pt. is found supine in the ditch,

complaining of right leg pain. The patient
is wearing a helmet and a small amount of
blood is noted on the right leg.
LOC (AVPU)
Alert.
Delegate Spine

Remove helmet.
Airway
Stridor? Silence?
Clear and open.
Breathing
Normal rate and depth of ventilations.

Circulation
quality
temp
- Deadly bleeding?
LOC (AVPU)
Localizes to pain.
Airway
Stridor? Silence?
Open and clear.
Breathing
Circulation
quality
temp
Radial pulse present, very rapid.

Pale, cool, clammy. * Deterioration
Reassess Neck
No change.
No change.
Rapid radial pulse present.
Reassess Abdomen
More tender in lower abdomen.
Normal, warm, and dry.
Reassess
interventions
N/A
Slight bleeding from right lower leg.
Head
- DCAP-BLS-TIC
- Raccoon Eyes
- Battles Signs
No sign of trauma (was wearing helmet).

No.
No.
No.
Neck
- DCAP-BLS-TIC
- JVD
No obvious injury.
Midline.
Flat neck veins.
Chest
- Expose.
- DCAP-BLS-TIC
Expose chest.
No obvious injuries found.
Present and equal.
Abdomen
- Expose.
- DCAP-BLS-TIC
Expose abdomen.
Slight tenderness of lower abdomen.
None.
Unstable and tender. Stabilize.
Upper Extremities
- DCAP-BLS-TIC
- Distal PMS
Reassess Chest
Rapid Trauma Survey
Lower Extremities
- DCAP-BLS-TIC
- Distal PMS
Open fracture of right lower leg with small

amount of bleeding. Good distal PMS.
Direct member to cover and stabilize.
Good distal PMS.
Secondary Survey
History
- Signs & Symptoms
- Allergies
- Medications
- Last Oral Intake
- Events
Vital Signs
- Blood pressure
- SPO2
- LOC / GCS
- Skin
- Pupils
My leg is killing me. Please help!

None.
None.
None.
2 hours ago.
I was on the back with my sister and we
hit a tree. How is she doing? I want her
with me!
90/70.
32, shallow but effective.
99% with O2 and assisted ventilations.
N / A.
4/5/6 = 5.
Pale, cool, clammy.
4mm, equal and reactive.
access at this time, and bolus if needed.
Head to Toe
- Head
- Neck
- Chest
- Breath sounds
- Abdomen
- Pelvis
- Lower extremities
- Upper extremities
No injuries noted.
Tender lower abdomen. No distention.
Do not reexamine.
89
ITLS Scenario 4 Marathon Runner Struck with Dyspnea / Tension Pneumothorax
Scene Size Up
Gloves. Goggles.
Scene Hazards
None.
Transport Decision
Number of Patients
One.
Packaging

equipment
You and your partner have arrived first on

scene. Fire department is en route, and
there is a first aider on scene.
Notification
Notify hospital immediately. Note that

patient is SOB, with a tension
pneumothorax requiring decompression.
Mechanism of Injury
A young male was struck on a marathon

route by a vehicle travelling approximately
80kph.
General Impression
- Patient activity
- Obvious Bleeding?
Patient is found lying semi-prone on his left

side. His eyes are closed on approach
and obvious respiratory distress is
heard. No obvious bleeding is observed.
LOC (AVPU)
Eyes open to verbal, patient appears

confused.
Delegate Spine
Direct team member to a p p l y c - s p i n e .
Airway
Stridor? Silence?
Clear and open.
Breathing
Rapid resps with shallow air movement.

Requires ventilations.
Circulation
quality
temp
- Deadly bleeding?
Airway
Stridor? Silence?
Clear and open.
Breathing
Rapid respirations with shallow air

movement. Continue ventilations.
Circulation
quality
temp
Radial pulses now absent. ** Change **

Carotid pulses still rapid and present.
Cyanotic, cool, clammy skin.
Reassess Neck
Visible tracheal deviation to right side.

Increased jugular vein distention
Reassess Chest
Absent air entry on left side
Reassess Abdomen
No changes
Ventilations still effective but decreased

compliance.
No major bleeding observed.
Rapid Trauma Survey

Head
- DCAP-BLS-TIC
- Raccoon Eyes
- Battles Signs
Matted blood in hair.

None observed.
None observed.
None observed.
Neck
- DCAP-BLS-TIC
- JVD
No injuries observed.
Possibly tracheal deviation to right side.
Distended jugular veins
Direct team member to apply collar.
Chest
- Expose.
- DCAP-BLS-TIC
Expose chest.
Contusions on left side of chest.
Crepitus and tenderness felt on palpation.
Hyper-resonant if percussed.
Decreased air entry on left side.
Abdomen
- Expose.
- DCAP-BLS-TIC
Expose abdomen.
Tender to palpate.
Slight distention.
Nothing significant found.
Lower Extremities
- DCAP-BLS-TIC
- Distal PMS
Left femur swelling, tenderness, deformity.

Expose. Direct team member to
stabilize if resources available.
Upper Extremities
- DCAP-BLS-TIC
- Distal PMS
No upper extremity injuries noted.
Eyes open to verbal, patient appears more

confused.
Weak, rapid pulses at radial and carotid.

Cyanotic, cool, clammy skin.

LOC (AVPU)
Initial Assessment
Secondary Survey
History
- Signs & Symptoms
- Allergies
- Medications
- Last Oral Intake
- Events
Cant breathe
Penicillin
Insulin
Diabetes
Unknown
He drove right over me!
Vital Signs
- Blood pressure
- SPO2
- LOC / GCS
- Skin
- Pupils
90/50
150
36, shallow unless ventilated
91% with assisted ventilations
5.6 if taken
3/4/5 = 12
Cool, pale, clammy
Equal and reactive
access and treat the hypovolemia (N/S
bolus) at this time.
Head to Toe
- Head
- Neck
- Chest
- Breath sounds
- Heart sounds
- Abdomen
- Pelvis
- Lower extremities
- Upper extremities
As before.
Increased tracheal deviation and JVD.
As before.
Absent air entry on left side.
As before.
Increased abdominal distention.
As before.
As before.
As before.
90
ITLS Scenario 5 - Fall from Balcony on 3 rd Floor, Hypoglycemic Pt with Scalp, Abdominal, Femur Injuries
ies
Scene Size Up
Gloves. Goggles.
Scene Hazards
None.
Transport Decision
Number of Patients
One.
Packaging

equipment
None.

move.
Mechanism of Injury
The patient was leaning over a third floor

balcony and fell.
Notification

have a confused patient with scalp,
abdominal and extremity injuries resulting
from a significant fall.
Initial Assessment
General Impression
- Patient activity
- Obvious Bleeding?
Pt. is found lying on left side holding onto

his left upper leg. A small amount of blood
is visible on the patients scalp. The
patient is obviously conscious and talking.
LOC (AVPU)
Alert but CONFUSED.
Delegate Spine
Airway
Stridor? Silence?
Clear and open.
Breathing
Normal rate and depth of ventilations.

Circulation
quality
temp
- Deadly bleeding?

Normal, warm, and dry.
Slight bleeding from scalp wound.
Rapid Trauma Survey

Head
- DCAP-BLS-TIC
-
Fluid leaks (ears / nose)

Raccoon Eyes
Battles Signs
Slight bleeding from scalp lac. Control.

Otherwise normal.
No.
No.
No.
Neck
- DCAP-BLS-TIC
- JVD
No obvious injury.
Midline.
Flat neck veins.
Chest
- Expose.
- DCAP-BLS-TIC
Expose chest.
Present and equal.
Abdomen
- Expose.
- DCAP-BLS-TIC
Expose abdomen.
Diffusely tender to palpation.
None.
Stable and non-tender.
Lower Extremities
- DCAP-BLS-TIC
Distal PMS
Upper Extremities
- DCAP-BLS-TIC
- Distal PMS
Closed fracture of left femur with swelling

and deformity.
Direct member to stabilize.
Good distal PMS.
Good distal PMS.

Patient INCREASINGLY confused. Pt.
states abdominal pain is worsening.
LOC (AVPU)
Airway
Stridor? Silence?
Clear and open.
Breathing
Circulation
quality
temp
Radial pulse weak and rapid.

Pale, cool, clammy. ** Deterioration
Reassess Neck
No change.
Reassess Chest
No change.
Reassess Abdomen
More tender in lower abdomen.
N/A
Secondary Survey
History
- Signs & Symptoms
- Allergies
- Medications
- Last Oral Intake
- Events
Vital Signs
- Blood pressure
- SPO2
- LOC / GCS
- Skin
- Pupils
I hurt all over.

Penicillin.
Insulin.
Diabetes.
Last night. Did not eat breakfast today.
I was standing on the balcony and
fainted.
110/70.
22, normal rate and depth.
99% with O2.
2.2 mmol/L
4/4/6 = 14.
Pale, cool, clammy.
Note: It is acceptable to initiate IV access
at this time, and bolus if needed.
Glucose should be administered.
Head to Toe
- Head
- Neck
- Chest
- Breath sounds
- Abdomen
- Pelvis
- Lower extremities
- Upper extremities
Scalp wound.
Increasing abdominal tenderness.
No changes.
91
ITLS Scenario
cenario 6 Gang Assault with Multi-system Trauma
Scene Size Up
No movement / sensation, good distal circ.
Gloves. Goggles.
Scene Hazards
None.
Number of Patients
One.
Transport Decision

equipment
Packaging
Mechanism of Injury
The patient is a young male who is found

in an alley. The police state that the
patient is a known criminal who has been
attacked by a gang.
Strap legs together to stabilize injuries.

Pt has a gunshot wound with moderate
bleeding over right kidney. Control.
Notification
Notify hospital immediately.
Initial Assessment
General Impression
- Patient activity
- Obvious Bleeding?
Patient is lying supine on the ground in the

alley. The eyes are closed, contusions are
noted on the face, minor blood is observed
on the left forearm and right lower leg.
LOC (AVPU)
Moans to pain.
Delegate Spine
Airway
Stridor? Silence?
Clear and open.
Breathing
Slow, shallow respirations. Direct team

member to assist ventilations.
Circulation
quality
temp
- Deadly bleeding?
Neck
- DCAP-BLS-TIC
- JVD
Clear and open.
Breathing
Slow, shallow respirations (rate of 8/min if

not ventilated). Continue ventilations.
Circulation
quality
temp
Radials absent, rapid at carotid.

Pale, cool, clammy.
Reassess Neck
No change.
No change.
Ensure ventilations still effective.
Moderate bleeds at left forearm and right

lower leg. Direct member to control.
Facial contusions noted.

Bleeding from right ear.
No.
Present on right side.
No obvious injury.
Midline.
Flat neck veins.
Clear air entry bilaterally.

Expose abdomen.
No injuries noted.
Soft, no tenderness.
Stable.
Upper Extremities
- DCAP-BLS-TIC
- Distal PMS
Moans to pain.
Airway
Stridor? Silence?
Reassess Abdomen
Abdomen
- Expose.
- DCAP-BLS-TIC
Distal PMS
LOC (AVPU)
Pale, cool, clammy
Expose chest.
No injuries noted.
No change.
Chest
- Expose.
- DCAP-BLS-TIC
Lower Extremities
- DCAP-BLS-TIC
Reassess Chest
Head
- DCAP-BLS-TIC
- Raccoon Eyes
- Battles Signs
Radials absent, rapid at carotid.
Rapid Trauma Survey
Deformed closed left femur fracture.

Moderately bleeding gunshot wound right
lower leg. Direct member to control and
stabilize. Good distal PMS.
Bleeding gunshot wound on left forearm.
Direct member to control and stabilize.
Secondary Survey
History
- Signs & Symptoms
- Allergies
- Medications
- Last Oral Intake
- Events
Vital Signs
- Blood pressure
- SPO2
- LOC / GCS
- Skin
- Pupils
Head and extremity trauma.

Unknown.
Unknown.
Unknown.
Unknown.
Found post assault in alley.
70/40.
140.
8 if unassisted.
No capture.
N / A.
1/1/5 = 7.
Pale, cool, clammy.
Left: 5mm and normal.
Right: 8mm and sluggish.
bolus) at this time. Target BP should be
110 systolic.
Head to Toe
- Head
-
Neck
Chest
Breath sounds
Abdomen
Pelvis
Lower extremities
Upper extremities
Multiple contusions, blood from right ear,

battles signs on right side.
Unchanged.
No injuries noted.
Equal air entry to bases.
Unchanged.
As before.
Deformed left femur. Dressed gunshot
wound on right leg. Good distal PMS.
Dressed gunshot wound on left forearm.
92
ITLS Scenario 7 - Scooter Collision, Conscious Pt with Spinal & Tibia Injuries
ies
Scene Size Up
Gloves. Goggles.
Scene Hazards
None.
Transport Decision
Number of Patients
One.
Packaging

equipment
The police are on scene and can assist.

move.
Mechanism of Injury
The patient on a scooter lost control on a

curve and collided with a guard rail. Police
called for EMS when they determined that
the patient couldnt move.
Notification

you have a conscious patient with spinal
deficits and a compound tibia fracture.
Initial Assessment
General Impression
- Patient activity
- Obvious Bleeding?
Pt. is found supine lying next to the guard

rail, wearing a motorcycle helmet. The
police have moved the scooter out of the
way. The pt states I cant feel anything. I
cant move.
LOC (AVPU)
Alert.
Delegate Spine

Remove helmet.
Airway
Stridor? Silence?
Breathing
Circulation
quality
temp
- Deadly bleeding?
Clear and open.
Normal rate, VERY shallow, diaphragmatic

breathing only.
Direct member to assist ventilations.
Normal, warm, sweaty.
None.
Rapid Trauma Survey

Head
- DCAP-BLS-TIC
- Raccoon Eyes
- Battles Signs
No sign of trauma (was wearing helmet).

No.
No.
No.
Neck
- DCAP-BLS-TIC
- JVD
Tender at base of neck.

Midline.
Flat neck veins.
Chest
- Expose.
- DCAP-BLS-TIC
Expose chest.
No injuries noted. No rib movement with
breathing. No sensation.
Present and equal.
Abdomen
- Expose.
- DCAP-BLS-TIC
Expose abdomen.
No injuries. No sensation.
Soft.
Stable to palpation. No sensation.
Lower Extremities
- DCAP-BLS-TIC
- Distal PMS
Right tibia protruding. Good distal pulse.

Direct member to cover and stabilize.
No sensation or movement.
Upper Extremities
- DCAP-BLS-TIC
- Distal PMS
No injuries detected. Weak grips

bilaterally. Good distal circulation.
LOC
(AVPU)
Airway
Stridor? Silence?
Breathing
Circulation

quality
temp
Reassess
Neck
Reassess
Chest
Reassess
Abdomen
Reassess
interventions
Alert. Still no feeling from neck down.

Clear and open.
Unchanged. Continue ventilations.

Radial pulse present.
Normal, warm, dry. * Change
No change.
No change.
No change.
Ensure ventilations remain effective.
Secondary Survey
History
- Signs & Symptoms
- Allergies
- Medications
- Last Oral Intake
- Events
I cant feel anything. I cant move.

None.
None.
None.
6 hours ago.
I was practicing so I could pass the test.
Vital Signs
- Blood pressure
- SPO2
- LOC / GCS
- Skin
- Pupils
70/50.
72.
12, very shallow if not assisted.
No capture.
N / A.
4/5/6 = 5.
Normal, warm, dry skin.
access at this time, and bolus if needed.
Head to Toe
- Head
- Neck
- Chest
- Breath sounds
- Abdomen
- Pelvis
- Lower extremities
- Upper extremities
No injuries noted.
Tender at base of neck.
Still only diaphragmatic breathing.
No injuries noted.
No injuries noted.
Unchanged from above. Good distal circ.
No injuries note. Good distal circ.
93
ITLS Scenario 8 Bombing at Office Building (Paralysis, Facial Burns with Airway Compromise)
Scene Size Up
Gloves. Goggles.
Scene Hazards
None.
Transport Decision
Number of Patients
One.
Packaging

equipment
You and your partner arrive on scene

shortly after the fire department.
Cool burns for 1-2 minutes. Cover with

clean sheet. Manually stabilize forearm.
Mechanism of Injury
There was a bombing of an office building.

Fire is on scene inside the building. The
patient is crumpled on the ground just outside
of an open door, yelling get me out of here,
my face is burning and I cant move!
Notification

patient has facial and airway burns, with
paralysis.
Initial Assessment

LOC (AVPU)
Alert
Airway
Stridor? Silence?
Stridor is noted with respirations. Hoarse

when speaking.
Breathing
Diaphragmatic but normal.
General Impression
- Patient activity
- Obvious Bleeding?
Patient is crumpled on the ground, yelling

get me out of here, my face is burning.
What is left of the patients shirt is
smoldering. Emergency Move Required.
LOC (AVPU)
Alert
Delegate Spine
Direct team member to apply c-spine

once safe.
Airway
Stridor? Silence?
Open. Pt. has a hoarse voice, and is

complaining that his face is burning. Red
burns are noted at nose and mouth.
Reassess Neck
No change.
Breathing
Diaphragmatic but normal. Direct team

member to apply high flow O2 via NRB.
Reassess Chest
No change.
Reassess Abdomen
No change.
Present, rate seems normal.
No ongoing interventions.
Circulation
quality
temp
- Deadly bleeding?
Normal, warm, dry (in unburned areas).

No major bleeding observed.
Rapid Trauma Survey

Head
- DCAP-BLS-TIC
- Raccoon Eyes
- Battles Signs
Neck
- DCAP-BLS-TIC
- JVD
Facial burns, singed nasal hairs, burns

inside mouth.
No fluid leaks, raccoon eyes, or battles
signs noted.
Blistering burns of the anterior neck.
Midline.
Flat neck veins.
Chest
- Expose.
- DCAP-BLS-TIC
Expose chest.
Burns on anterior chest.
No movement of ribs during breathing, only
diaphragm.
Abdomen
- Expose.
- DCAP-BLS-TIC
Expose abdomen.
No injuries noted.
Soft, no tenderness.
Stable.
Lower Extremities
- DCAP-BLS-TIC
- Distal PMS
No sign of trauma.
Upper Extremities
- DCAP-BLS-TIC
- Distal PMS
Obvious open fracture of left forearm.

Circulation
quality
temp
Present, rate seems normal.

Normal, warm, dry (in unburned areas).
Secondary Survey
History
- Signs & Symptoms
- Allergies
- Medications
- Last Oral Intake
- Events
Vital Signs
- Blood pressure
- SPO2
- LOC / GCS
- Skin
- Pupils
I cant feel anything from my neck down

NKA
None
Patient states healthy
6 hours ago
I had just entered the lab when an
explosion threw me out the doorway
70/40
65
12, diaphragmatic breathing
No capture
N/A
4/5/6 = 15
Normal, warm, dry (in unburned areas)
Equal and reactive
bolus) at this time.
Head to Toe
- Head
-
Neck
Chest
Breath sounds
Abdomen
Pelvis
Lower extremities
Upper extremities
Facial burns, singed nasal hairs, burns

inside mouth.
Blistering burns of the anterior neck,
tenderness with palpable step off.
Anterior chest burns.
Equal air entry.
No sign of trauma.
As before.
As before. Still no movement or sensation
Left forearm fracture. Still no movement or
sensation.
94
ITLS Scenario
enario 9 Vehicle Collides with Power Plant, Driver near a Vehicle with Hazards
Scene Size Up
Gloves. Goggles.
Scene Hazards
There is an obvious gas leak underneath

the vehicle, and thick smoke is visible
coming out of the engine compartment.
Pt. requires emergency move.
Number of Patients
One.

equipment
Mechanism of Injury
Head on collision, car into a power plant.

Unrestrained driver was thrown from
vehicle and is found lying on the ground
approximately 6 from the vehicle.
Initial Assessment
General Impression
- Patient activity
- Obvious Bleeding?
Unresponsive patient initially found lying

on ground approximately 6 from vehicle.
** Pt. should have been rapidly moved.
LOC (AVPU)
Localizes to pain.
Delegate Spine
Airway
Stridor? Silence?
Clear and open. ** Gag reflex present if

OPA attempted.
Breathing
Normal rate and depth.

Circulation
quality
temp
- Deadly bleeding?
Transport Decision
Packaging
Notification

should include that you are en route with
the unrestrained driver of a high speed
MVI. Patient has an altered LOC with
head, chest, and abdominal trauma.
Rapid Trauma Survey

Head
- DCAP-BLS-TIC
- Raccoon Eyes
- Battles Signs
Contusion on forehead.
No.
No.
No.
Neck
- DCAP-BLS-TIC
- JVD
No obvious injury.
Midline.
Flat neck veins.
Chest
- Expose.
- DCAP-BLS-TIC
Expose chest.
Sternal contusions. Crepitus over sternum
and anterior ribs, Moans when palpated.
Abdomen
- Expose.
- DCAP-BLS-TIC
Expose abdomen.
Painful, moans when palpated.
Rigid and distended.
Stable.
Lower Extremities
- DCAP-BLS-TIC
- Distal PMS
No injuries noted.
Good distal PMS.
Upper Extremities
- DCAP-BLS-TIC / PMS
LOC (AVPU)
Localizes to pain.
Airway
Stridor? Silence?
Clear and open. ** No gag reflex if

airway adjunct re-attempted at this time.
Breathing
Normal rate and depth.
Circulation
quality
temp

Pale, cool, clammy. ** Deterioration
Reassess Neck
No change.
Reassess Chest
No change.
Reassess Abdomen
No change.
None performed at this time.
Secondary Survey
Normal, warm, dry skin.

No external bleeding noted.
History
- Signs & Symptoms
- Allergies
- Medications
- Last Oral Intake
- Events
Head, chest, abdominal trauma.

Unknown.
Unknown.
Unknown.
Unknown.
Unrestrained driver in head on MVI.
Vital Signs
- Blood pressure
- SPO2
- LOC / GCS
- Skin
- Pupils
80/60
20, regular
98% with O2.
N / A.
2/1/5 = 8.
Pale, cool, clammy.
Note: It is acceptable to initiate IV access
and treat the hypovolemia (N/S bolus) at
this time. Target BP should be
110 systolic due to potential head injury.
Head to Toe
- Head
-
Neck
Chest
Breath sounds
Abdomen
Pelvis
Lower extremities
Upper extremities
Contusion on forehead. No fluid leaks, no

raccoon eyes or battles signs.
Sternal contusions.
Equal air entry to bases.
Rigid, distended, painful to palpation.
No injuries noted.
95
ITLS Scenario 1 0 - Factory Incident with Crush, Pt with Skull #, Abdominal Protrusion, Pelvic #, Crushed Legs
gs
Scene Size Up
Gloves. Goggles.
Scene Hazards
None. The machine is stopped.
Transport Decision
Number of Patients
One.
Packaging

equipment
Co-workers are on scene and can assist.

move (minor abrasions on back).
Notification
Mechanism of Injury
The patient fell into heavy machinery at a

factory. Co- workers stopped the
machine, removed the patient, and laid
him on the floor.

have an unconscious crush injury patient
with head, open abdominal, pelvic and
lower limb injuries.
Initial Assessment
General Impression
- Patient activity
- Obvious Bleeding?
Pt. is found supine on the ground next to

the stopped machine. The patients eyes
are closed, there is no movement, and
blood is visible on the shirt and pants.
LOC (AVPU)
Localizes to pain.
Delegate Spine
Airway
Stridor? Silence?
Clear and open.
Breathing
Normal depth of ventilations, but very slow.

Direct member to assist ventilations.
Circulation
quality
- Skin colour / cond /
temp
- Deadly bleeding?
Radial absent, carotid weak and rapid.

Pale, cold, clammy skin.
From abdomen and both legs.
Rapid Trauma Survey

Head
- DCAP-BLS-TIC
- Raccoon Eyes
- Battles Signs
Bruising to right side of face.

Bloody fluid from right ear.
No.
No.
Neck
- DCAP-BLS-TIC
- JVD
No obvious injury.
Midline.
Flat neck veins.
Chest
- Expose.
- DCAP-BLS-TIC
Expose chest.
Present and equal.
Abdomen
- Expose.
- DCAP-BLS-TIC
Expose abdomen.
Protruding viscera with moderate bleeding.
Tender. Cover.
Very unstable.
Lower Extremities
- DCAP-BLS-TIC
- Distal PMS
Both legs crushed and mangled from

upper thighs down. Severe bleeding.
Control bleed and stabilize. Direct
pressure ineffective, tourniquets
required.
No distal pulses, motor, or sensation.
Upper Extremities
- DCAP-BLS-TIC
- Distal PMS
No distal pulses, motor, or sensation.
LOC (AVPU)
Localizes to pain.
Airway
Stridor? Silence?
Clear and open.
Breathing
Very slow rate if not assisted.

Continue assisted ventilations.
Circulation
quality
temp
Radial absent, carotid weak and rapid.

Pale, cool, clammy.
Reassess Neck
No change.
Reassess Chest
No change.
Reassess Abdomen
No change.
Reassess
interventions
Continue assisted ventilations.
Secondary Survey
History
- Signs & Symptoms
- Allergies
- Medications
- Last Oral Intake
- Events
Vital Signs
- Blood pressure
- SPO2
- LOC / GCS
- Skin
- Pupils
Patient unresponsive.
None.
None.
Diabetic.
4 hours ago.
The supervisor saw him fall in and yelled
to stop the machine. By the time we got
him out he was badly hurt!
50/0.
RR=8 if not assisted.
No capture.
N / A.
2/1/5 = 8.
Pale, cool, clammy.
Left: 4mm and reactive.
Right: Dilated and non-reactive.
access at this time, and bolus to a
maximum systolic pressure of
110mm/Hg (due to head injury).
Head to Toe
- Head
-
Neck
Chest
Breath sounds
Abdomen
Pelvis
Lower extremities
Upper extremities
Battles Sign behind R ear. Bloody fluid

from R ear. Bruising to R side of face.
Bleeding controlled with dressings.
Do not reexamine.
96
ITLS SCENARIO GRADE SHEET

Student Name:
Time
Started:
Date:
ACTION
Time
Primary completed:
9
COMMENTS
Scene Hazards
[ ] Practice
[ ] Test
[ ] RT
Time
Secondary completed :
ACTION
PATIENT ASSESSMENT PRIMARY SURVEY

Scene Size-up
[ ] Basic
[ ] Advanced
Scenario #:
Time
Transported:
COMMENTS
Baseline Vital Signs HR, RR, BP

History SAMPLE
Number of Patients
IF ALTERED MENTAL STATUS

Pupils Size? Reactive? Equal?
Need for More Help or Equipment
Glasgow coma scale
Mechanism of Injury
Orientation, emotional state
General Impression
Age, Sex, Weight
Signs of cerebral herniation
General Appearance
Blood glucose
Medical identification devices
Body Position
Position in Environment
Critical transport decision
Patient Activity
ACTION
ONGOING ASSESSMENT
Obvious Severe Injury or Major Bleeding
(If major bleeding, go to CABC)
Subjective Ask patient if changes in how feels
LOC AVPU
Reassess mental status LOC, pupils
Airway Snoring, Gurgling, Stridor, Silence
If altered mental status Recheck GCS
Breathing Present? Rate, Depth, Effort
Reassess airway
Radial/Carotid Pulses
Present? Rate, Rhythm, Quality
Reassess breathing and circulation

Recheck vital signs
Skin Color, Temp, Moisture, Capillary Refill

Uncontrollable External Hemorrhage?
Head and Neck
Major facial injuries
Bruising, swelling, penetrations
Subcutaneous emphysema?
Neck vein distention?
Tracheal deviation?
Chest Look: Asymmetry, Contusion,
Penetrations, Paradoxical Motion, Chest Rise
Feel: Tenderness, Instability, Crepitation
Breath Sounds
Present? Equal?
If decreased breath sounds, percussion
Heart Tones
Abdomen
Look: bruising, penetration/evisceration
Gently palpate: tenderness, rigidity, distention
Pelvis Deformity, penetrating wounds, TIC
Lower Extremities
Upper: swelling, deformity, TIC
Lower: scan wounds, swelling, deformity
COMMENTS
Skin color, condition, temperature

Check for neck vein distention
Check for tracheal deviation
Recheck chest
Breath sounds Quality? Equal?
Reassess heart sounds
Reassess abdomen if possible injury
Development of tenderness, distention, rigidity
Check all identified injuries
For example:
Lacerations for bleeding
PMS distal to injuries on extremities
Flail segments
Pneumothorax
Open chest wounds
Check all interventions
For example:
ET tube for patency and position
Oxygen for flow rate
IVs for patency and fluid rate
Seals on sucking chest wounds
Patency of decompression needle
Splints and dressings
Impaled objects for stabilization
If pregnant, body position
Cardiac monitor, Sp02, EtCO2
Motor, sensory before transfer to backboard

Upper Extremities
Scan wounds, swelling, deformity
Motor, sensory before transfer to backboard
Posterior Penetrations, deformity, edema
IF CRITICAL, TRANSFER TO AMBULANCE
GRADE KEY:
[ 9 ] Completed, skill performed in sequence

[ D ] Delayed, performed out of sequence
[ X ] Skill not performed, too late or incorrectly
June 2011
97

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ITLS Scenario 1 - GSW with Dyspnea, Hemothorax, Extremity Injury

Transport Decision / Packaging / Notification

None. The police have secured the scene.

Unstable, load and go.

Need for more help or

Police are on scene and can assist.

Check posterior during roll onto board.

You have been called to the scene of a

Notify hospital immediately. Notification

Pt. is found supine, conscious, with

Clear and open.

Clear and open.

Rapid, shallow, gasping respirations.

Rapid, shallow, gasping respirations.

Direct team member to apply c-spine.

Rapid radial pulses present.

Expose chest. Sucking chest wound on

Breath Sounds (2 points)

No breath sounds on right side.

Deformity of left forearm. Stabilize.

Rapid, weak radial pulses.

Reassess Vital Signs

* In repeat ongoing assessments

Ensure ventilations still effective.

Rapid Trauma Survey

Ongoing Exam (every 5 minutes for unstable pt)

Transport Decision / Packaging / Notification

None. The vehicle is stable.

Unstable, load and go.

Need for more help or

Police are on scene and can assist.

Extricate patient onto board. Ensure

The patient is an unrestrained pregnant

Notify hospital immediately. Notification

Pt. is found sitting in the drivers seat of the

Direct team member to apply c-spine.

Clear and open.

Normal rate and quality.

Rapid radial pulses present.

Rapid Trauma Survey

Breath Sounds (2 points)

Present and equal.

Pain on palpation. Unstable.

Left leg flexed at hip and knee, internally

Ongoing Exam (every 5 minutes for unstable pt)

- Rate, Depth, Effort

- Pulse rate / rhythm /

Reassess Vital Signs

Normal rate and quality.

My hip hurt so bad! My chest and

Transport Decision / Packaging / Notification

Unstable, load and go.

Need for more help or

The police are on scene and can assist.

Direct member to strap legs together.

The patient was thrown from a motorcycle

Notify hospital immediately. Note that you

Pt. is found supine in the ditch,

Direct team member to apply c-spine.

Clear and open.

Normal rate and depth of ventilations.

Open and clear.

Normal rate and quality.

Radial pulses now absent. Change