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Initial Assessment
and Management
of Trauma
Purwoko Sugeng H
Overview
• Patient Assessment
– Primary Survey
– Ongoing Exam
– Secondary Survey
• Initial Assessment related to
– Rapid Trauma Survey vs. Focused Exam
– Interruptions
• Critical conditions and the “Fix It” process
Introduction
• Golden Hour
– Time to reach operating room
(or other definitive treatment)
– NOT time for transport to ED
– NOT time in Emergency Department
• EMS does NOT have a Golden
Hour
• EMS has a Platinum Ten Minutes
Home
Introduction
• Patients in their Golden Hour must:
– Be recognized quickly
– Have only immediate life threats managed
– Be transported to an APPROPRIATE facility
• Survival depends on assessment skills
• Good assessment results from
– An organized approach
– Clearly defined priorities
– Understanding available resources
Home
Trauma Assessment
P Scene Size Up
R
I
Initial Assessment
M
A
R
Y Load and Go
Situation ?
S Rapid
U Focus
Trauma
Assessment
R Survey
V
E
Load and Go
Y Situation ? HOSP
SECONDARY
ONGOING EXAM
SURVEY
Scene Size-Up
• Standard Precaution
• Scene Hazard
• Number of Patients
• Need for help or equipment
• Mechanism of Injury(MOI)
Standard Precaution
• Extrication
• Traffic control
• Utilities
Significant Mechanism
of Injury
Ejection from vehicle High-speed vehicle
collision
Death in same
passenger Vehicle-pedestrian
compartment collision
Fall of greater than Motorcycle crash
15 feet or
Unresponsive or altered
3 times the patient’s
mental status
height
Penetrating injury of head,
Rollover of vehicle
chest, or abdomen
Home
Bent Steering Wheel Broken Mirror
Spider-Webbed
Windshield
Deformed
Distorted Pedals Dashboard
Home
Initial Assessment
• General Impression
• Mental Status
• Airway
• Breathing
• Circulation
General Impression
• Age, Weight, Gender
• Position (relative to posture and
surroundings)
• Activity
• Obvious Injuries/Bleeding
Assess Mental Status
• Take C-Spine control
• A – Alert and immediately
responsive
• V – Responsive to verbal stimuli
• P – Responsive to painful stimuli
• U – Unresponsive
Assess Airway
• Open if necessary using jaw-thrust
maneuver
• Consider oro- or naso-pharyngeal
airway
• Note unusual sounds and correct
cause
– Snoring – oro-/naso-pharyngeal airway
– Gurgling – suction
– Stridor – consider intubation
– Silence
Correcting silence
• Attempt ventilation
• Reposition
• Heimlich
• Visualize and remove
• Intubate
• Trans-laryngeal jet insuflation
Assess Breathing
Abrasions Punctures/Penetrations
Burns Tenderness
Lacerations Swelling
Rapid Trauma Survey
Head
Neck
Chest
Abdomen
Pelvis
Extremities
Posterior
Head: DCAP-BTLS + Crepitation
Mid-clavicular Mid-axillary
Abdomen: DCAP-BTLS + Firmness and Distention
Posterior: DCAP-BTLS
Package and begin transport
• Immediate – immobilize, load, go
• Delayed – immobilize, treat as
necessary, transport
Critical Interventions
Home
Secondary Survey
• As appropriate, considering
priority
• History and vital signs,
neurological
• Repeat initial assessment
• Complete critical interventions
• Careful head to toe survey
(DCAP/BTLS)
Detailed Physical Exam
Head to Toe
• Head – DCAP/BTLS and creptiation
• Ears – DCAP/BTLS and blood/fluid
• Face – DCAP/BTLS and blood/fluid
• Eyes – DCAP/BTLS and discoloration,
pupils, foreign bodies, blood
• Nose – DCAP/BTLS and blood/fluid
• Mouth – DCAP/BTLS and teeth, foreign
bodies, swelling, lacerations, odor
Head to Toe
Detailed Physical Exam
Head to Toe
• Neck – DCAP/BTLS and JVD, crepitation
• Chest – DCAP/BTLS and palpate for paradoxical
motion, symmetry, crepitation, and auscultate
breath sounds
• Abdomen – DCAP/BTLS and tenderness,
rigidity, distention
• Pelvis – DCAP/BTLS and pain, tenderness,
motion, crepitation
• Upper extremities – DCAP/BTLS and PMS
• Lower extremities – DCAP/BTLS and PMS
• Posterior – DCAP/BTLS
Summary
• Patient Assessment
– Key to trauma care
– Not difficult, but time-critical
– Rapid, orderly, thorough
• Remain calm
– Maximize speed through organization
and teamwork
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