Initial Assessment and Management of Trauma

Capt. Mike Bevers Physicians Assistant, 173rd MDF

Introduction
Trauma

Leading killer from ages 1 to 44 Up to one-third of deaths are preventable

Introduction
Golden

Hour

Time to reach operating room NOT time for transport NOT time in Emergency Department

Introduction
EMS EMS

does NOT have a Golden Hour

has a Platinum Ten Minutes

Introduction
Patients

in Golden Hour must be:

Recognized quickly Transported to APPROPRIATE facility

Introduction
Survival Good

depends on assessment skills

assessment results from

An organized approach Clearly defined priorities

Size-Up
Safety

Scene
How does scene look? How many patients? Where are they? Situation Additional resources? Critical vs non-critical patient?

Initial Assessment (Primary Survey)

Find

life threats If life threat present, CORRECT IT! If life threat cant be corrected
Support ABCs TRANSPORT!!

Primary Survey
With critical trauma you may never get beyond primary survey

Airway with C-Spine Control (if MOI dictates)

You

dont need a C-collar yet head to neutral position

Return

Stabilize

without traction
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Airway
Noisy

breathing is obstructed breathing all obstructed breathing is not noisy

But

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Airway
Anticipate

airway problems with

Decreased level of consciousness Head trauma Facial trauma Neck trauma Upper chest trauma
Open

it, Clear it, Maintain it

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Breathing
Is Is

air moving? it moving adequately?

Is

oxygen getting to the blood?

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Breathing
Look Listen Feel
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Breathing
Give

Oxygen immediately if:

Decreased level of consciousness ? Shock ? Severe hemorrhage Chest pain Chest trauma Dyspnea Respiratory distress
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Breathing
If you think about giving oxygen, GIVE IT!!

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Breathing
Consider

assisting ventilations if:

Respirations <12 Respirations >24 Shallow respirations Respiratory effort increased

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Breathing
If you cant tell if ventilations are adequate, they arent!! If you are wondering whether or not to bag the patient, you should!!
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Breathing
If

respirations are compromised:

Expose chest
Inspect front and back Palpate front and back

Auscultate front and back

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Circulation
Is Is Is

heart beating?
there serious external bleeding? the patient perfusing?

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Circulation
Does

patient have radial pulse?

Absent radial = systolic BP < 80

Does

patient have carotid pulse?

Absent carotid = systolic BP < 60

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Circulation
No

carotid pulse?

Extricate CPR Pneumatic Antishock Garment Run!!!!

Survival

rate from cardiac arrest secondary to blunt trauma is < 1%

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Circulation
Serious

external bleeding?

Direct pressure (hand, bandage, PASG) Tourniquet as last resort

All

bleeding stops eventually!

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Circulation
Is

patient in shock?

Cool, pale, moist skin = shock, until proven otherwise

Capillary refill > 2 sec = shock until proven otherwise Restlessness, anxiety, combativeness = shock until proven otherwise
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Circulation
If

possible internal hemorrhage, QUICKLY expose, palpate:

Abdomen 2 liters

Pelvis 2 liters
Thighs 1.5 liter / side
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Disability (CNS Function)

Level

of Consciousness = Best brain perfusion indicator AVPU initially pupils

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Use

Check

The eyes are the window of the CNS

Disability (CNS Function)

Decreased LOC in trauma = Head injury until proven otherwise

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Expose and Examine

You

cant treat what you dont find! If you dont look, you wont see! Remove ALL clothing from critical patients ASAP Avoid delaying resuscitation while disrobing patient Cover patient with blanket when finished
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The Load and Go Situations

Head injury with decreased LOC Airway obstruction unrelieved by mechanical methods Conditions resulting in inadequate breathing Shock Conditions that rapidly lead to shock Tender, distended abdomen Pelvic instability Bilateral femur fractures Traumatic cardiopulmonary arrest

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Rapid Trauma Assessment

DCAP-BTLS D - Deformities C - Contusions A - Abrasions P - Punctures/Penetrations B - Burns T - Tenderness L - Lacerations S - Swelling

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Initial Assessment
A blood pressure or an exact respiratory or pulse rate is NOT necessary to tell that your patient is critical !!!!!

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Initial Assessment
If the patient looks sick, hes sick!!!

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Initial Resuscitation
Treat

as you go!

Aggressively

correct hypoxia and inadequate ventilation. external blood loss.

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Control

Initial Resuscitation
Immobilize

C-spine ? MOI (rigid collar) Keep airway open Oxygenate Rapidly extricate to long board Begin assisted ventilation with BVM Expose Apply and inflate PASG Transport Reassess and report in route

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Initial Resuscitation
Minimum Time On Scene Maximum Treatment In Route
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Detailed Exam (Secondary Survey)

History

and Physical Exam You WILL get here with MOST trauma patients Perform ONLY after initial assessment is completed and life threats corrected Do NOT hold critical patients in field for detailed exam
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Physical Exam
Head Every Top

to Toe, organized approach

patient, same way, every time

to bottom; near to far, front & back

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Look--Listen--Feel

History
Chief

complaint What PATIENT says problem is Not necessarily what you see

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History
A

= Allergies M = Medications P = Past medical history L = Last oral intake E = Events leading up to incident

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Definitive Field Care

Performed ONLY on stable patients

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Definitive Field Care

Stable

patients can receive attention for individual injuries before transport

Bandaging Splinting

Reassess

carefully for hidden problems

If

patient becomes unstable at any time, TRANSPORT

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Reevaluation
Ventilation

and perfusion status

Repeat

vital signs
stabilization of identified reassessment for unidentified
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Continued

problems
problems

Continued