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TRAUMA
OBJECTIVES
As a Medic, you should be able to:
Establish priorities of care based on lifethreatening conditions. Distinguish between patient assessment and patient management. Explain the purpose of the primary and secondary survey. Detail in the correct order the assessment of each component of the primary survey.
OBJECTIVES
As a Medic, you should be able to:
Identify potentially life-threatening conditions that can be discovered in the primary survey. Discuss patient management techniques that may be used if abnormalities are found in the primary survey. Differentiate between resuscitation procedures for medical patients and trauma patients.
OBJECTIVES
As a Medic, you should be able to:
Describe the examination techniques for inspection, palpation, and auscultation. Explain in detail the physical examination for each component of the secondary survey. Apply effective patient-interviewing techniques to given scenarios. Describe the essential elements of the patient history
OBJECTIVES
As a Medic, you should be able to:
Describe the process of patient reevaluation. Describe special considerations in assessing pediatric, geriatric, disabled, and nonEnglish-speaking patients.
How many patients: Consider triage if two or more. Triage is initiated by the senior medical provider at the scene. He rapidly surveys each casualty and places them in a triage category.
Note:
Spinal stabilization can be directed by the primary care provider if there is more than one provider - USE YOUR ASSETS. The C-Collar is not placed on the patient at this time - it is placed on the patient after the neck is assessed in the rapid trauma assessment.
GENERAL IMPRESSION
The general impression is your immediate assessment formed in the first few seconds of exposure to the patients environment combined with the chief complaint. What is the MOI and does the patient have any life threatening injuries? (This is not verbalized to the patient but will be verbalized for classroom scenarios).
DETERMINE RESPONSIVENESS/LOC
A - Alert, responds without prompting. V - Verbal stimulus, responds to verbal commands (not necessarily appropriately) P - Painful stimulus, withdraws or groans when pain is elicited (sternal rub/nail bed). U - Unresponsive, does not respond to verbal or painful stimuli.
Identify injuries that may compromise the airway/breathing (open chest wound) or produce profound irreversible shock (massive external hemorrhage). Manage rapidly and temporarily at this time.
If the patient is found in any other position other than supine, you may have to reposition to provide appropriate care. If required this must be done with spinal immobilization. If appropriate care can be given with the patient in the position found, defer movement until it interferes with treatment.
If the patient is alert and oriented - move to assess the patients breathing. If the patient has an altered LOC consider the following: NOTE: THIS MUST BE ACCOMPLISHED WITHIN 5 MINUTES OF STARTING THE ASSESSMENT
MODIFIED JAW THRUST: For Trauma and suspected C-Spine injury. HEAD-TILT, CHIN-LIFT: For Medical.
Clear Airway as required: (suction/Heimlich/laryngoscopic)
ASSESS AIRWAY
LOOK - I see bilateral rise and fall of the chest. LISTEN - I hear deep and normal respiratory effort. FEEL - I feel exhalation on my ear. NOTE: The rate is not counted, but continuous practice and experience allows you to guestimate the rate.
REASSESS AIRWAY
LOOK - I see bilateral rise and fall of the chest. LISTEN - I hear deep and normal respiratory effort. FEEL - I feel exhalation on my ear. At this time it appears I have adequate placement of my airway adjunct.
ASSESS BREATHING
APPROXIMATE RATE: Use the method of abnormal vs. normal rate. (<10 or >28). Slow or Rapid. RHYTHM: Regular vs. Irregular. DEPTH: Shallow vs. Deep.
Non-Rebreather face mask: Normal rate and depth. Bag Valve Mask with Reservoir: For abnormal or inadequate respirations.
ALL TRAUMA PATIENTS RECEIVE HIGH CONCENTRATION OXYGEN. IT IS ESSENTIAL TO INCREASE THE OXYGEN CARRYING CAPABILITY OF THE BLOOD TO PREVENT BRAIN DAMAGE AND ORGAN FAILURE DUE TO HYPOXIA IN THE HEMODYNAMICALLY CHALLENGED PATIENT.
Proper assessment of airway interventions and inspection for life threatening injuries requires exposure of the thorax
Inspect the anterior thorax for obvious lifethreatening injuries. (i.e. Sucking Chest Wound) Manage injuries that are immediately life threatening or compromise breathing.
The patients lung fields should be auscultated at the apices X 1 bilateral for the presence of breath sounds. Decreased or absent breath sounds may indicate tension pneumothorax. assess placement of ET tube and BVM if assisting ventilations.
Palpate the anterior chest for obvious rib fractures or flail segments that may produce a difficulty for the patient to breath.
Palpate the posterior thorax by using a raking technique in an attempt to feel any penetrating or exit wounds. Use caution to prevent unnecessary spinal manipulation. Continuously look at your gloves for signs of blood.
TREATMENTS
TREAT ALL INJURIES THAT CAN OR WILL CREATE COMPLICATIONS WITH AIRWAY OR BREATHING. PATIENTS THAT ARE NOT BREATHING OR BREATHING INADEQUATELY DETERIORATE RAPIDLY.
ASSESS CIRCULATION
CAROTID PULSE: BP is > 60. FEMORAL PULSE: BP is > 70. RADIAL PULSE: BP is > 80.
ASSESS PULSE
If the patient is alert - assess the radial pulse. If the patient has a decreased LOC - assess both the carotid and radial pulses simultaneously. If no pulse - begin CPR.
ASSESS PERFUSION
Assessment of perfusion can be easily accomplished in three ways: Capillary refill - < 2 seconds Skin color - In light skinned patients color will be obvious, in dark skinned patients it is easiest to assess the mucous membranes of mouth or fingernail beds. Skin temperature - Warm.
Assess the patient for major bleeding, perform a blood sweep from the patients head to their toes, if you need to expose the patient, do so to manage life-threatening bleeding. NOTE: If life-threatening bleeding is detected it will be managed immediately.
NON LIFE-THREATENING INJURIES AND MEDICAL PATIENTS: Focused history and physical exam. LIFE-THREATENING OR MOI CONSIDERED TO BE HIGH RISK: Rapid Trauma Assessment.
EXPOSE
Complete exposure of the patient is required to perform an adequate rapid trauma assessment and detailed physical exam. NOTE: Some injuries, such as pelvis or femur fractures can cause massive internal hemorrhage. They can also be easily missed due to the lack of external bleeding.
REASSESS
Obvious head injuries. Maxillofacial injuries that can compromise the airway. Severe bleeding. Cerebral Spinal Fluid from nose or ears.
Obvious injuries. (Treat all injuries to the neck at this point as rapidly as possible). Jugular Vein Distention (JVD). Tracheal Deviation. Medical Alert Tags. Palpate C-Spine for deformities.
APPLY C-COLLAR
Should be applied as soon as possible after inspection of neck. If not applied at this point, it must be applied prior to moving or rolling the patient.
Obvious injuries: Contusions and abrasions over the chest wall. Penetrating wounds (Sucking Chest Wound). Paradoxical motion. Palpate for crepitus and flail segments.
Stable or Unstable. Consider MAST at this point for stabilization of a fractured pelvis but do not apply at this time. Application of MAST is recommended prior to moving the patient.
Inspect Palpate NOTE: At this time, all you will be concerned about is looking for major hemorrhage and long bone fractures. Reassess previous treatments and treat lifethreatening injuries. Consider alignment to assist with hemorrhage control
Inspect Palpate NOTE: At this time, all you will be concerned about is looking for major hemorrhage and long bone fractures. Reassess previous treatments and treat lifethreatening injuries. Consider alignment to assist with hemorrhage control
LOG ROLL
NOTE: THE C-COLLAR MUST BE APPLIED PRIOR TO ROLLING OR MOVING A PATIENT WITH A SUSPECTED C-SPINE INJURY. Maintain C-Spine and L-Spine control and in line. Consider MAST. Assess the posterior from head to foot.
Signs and Symptoms. Allergies. Medications. Pertinent past medical history. Last oral intake(time or hours ago). Events leading up to the injury/illness. NOTE: It may be required to gain this information from bystanders at the scene or family members in better condition.
INITIATE TRANSPORTATION
The golden hour begins with injury to the patient not with the arrival of EMS. Trauma patients are not resuscitated in the field only in the E.D. or O.R. NOTE: TRANSPORTATION OF THE PATIENT MUST BE INITIATED WITHIN 10 MINUTES OF STARTING THE ASSESSMENT.
Two large bore (18ga. or larger) Catheters. Ringers Lactate or Normal Saline. NOTE: For test purposes a patent IV must be established in less than 3 attempts. The second IV will be moulaged or simulated. Reassess ABCs and treatments after each IV is initiated.
Pulse- Rate, Strength, and Rhythm. Respirations- Rate, Depth, Rhythm. Blood Pressure- During transportation it may be difficult to auscultate the diastolic due to noise. BP by palpation may be substituted. Temperature- If heat injury or exposure to cold is suspected. *NOTE: You may direct assistant to obtain.
REASSESS
Airway - ET tube. Breathing - Rate, rhythm, depth, BVM. Note: Dont forget to check you O2 tank! Circulation - Pulses/Cap refill. Treatments on serious injuries IVs (infiltration, still running, bags not empty).
Inspect and palpate the scalp DCAP-BTLS. Head- battle signs. Eyes- Coons eyes. Ears- Blood/CSF. Nose- Blood/CSF. Throat/Mouth- Airway obstructions and interventions. Treat all minor injuries.
Inspect the neck (DO NOT REMOVE CCOLLAR). Reassess for JVD. Reassess for tracheal deviation. Injuries that were treated before the CCollar.
Assess in a similar fashion to checking for pelvis stability. Assess for fractured clavicles. NOTE: Fractures to the shoulder girdle carry a high suspicion of C-spine involvement/injury.
Inspect. Auscultate X3 bilaterally. Auscultate the heart (note rate, rhythm) Percuss X3 bilaterally. Palpate. Treat minor injuries/Reassess treatments.
ATTACH ECG
NOTE: If available. Interpret ECG - tachycardia, PEA/EMD. Myocardial Contusion - PVCs/PACs.
Inspect the abdomen. Palpate all 4 quadrants for distention, masses, pain, tenderness, guarding. Assess the pelvis for stability. Treat minor injuries, Reassesses MAST/previous treatments. NOTE: DO NOT OVERMANIPULATE THE UNSTABLE PELVIS!
Inspect and palpate both legs. Assess motor, sensory, and circulatory function of both legs. Treat/splint minor injuries Reassess previous treatments/MAST.
Inspect and palpate both arms. Assess motor, sensory, and circulatory function of both arms. Treat/splint minor injuries Reassess previous treatments/IVs.
THE END
The detailed physical exam, to include IVs will be completed in 12 minutes. The time for the IV itself will be 6 minutes.
T I O S E NS U Q ? ?