Initial Assess Trauma

3,542 views

Published on

Capt. Mike Bevers
Physician’s Assistant, 173rd MDF

Initial Assess Trauma

  1. 1. Initial Assessment and Management of Trauma Capt. Mike Bevers Physician’s Assistant, 173 rd MDF
  2. 2. Introduction <ul><li>Trauma </li></ul><ul><ul><li>Leading killer from ages 1 to 44 </li></ul></ul><ul><ul><li>Up to one-third of deaths are preventable </li></ul></ul>
  3. 3. Introduction <ul><li>Golden Hour </li></ul><ul><ul><li>Time to reach operating room </li></ul></ul><ul><ul><li>NOT time for transport </li></ul></ul><ul><ul><li>NOT time in Emergency Department </li></ul></ul>
  4. 4. Introduction <ul><li>EMS does NOT have a Golden Hour </li></ul><ul><li>EMS has a Platinum Ten Minutes </li></ul>
  5. 5. Introduction <ul><li>Patients in Golden Hour must be: </li></ul><ul><ul><li>Recognized quickly </li></ul></ul><ul><ul><li>Transported to APPROPRIATE facility </li></ul></ul>
  6. 6. Introduction <ul><li>Survival depends on assessment skills </li></ul><ul><li>Good assessment results from </li></ul><ul><ul><li>An organized approach </li></ul></ul><ul><ul><li>Clearly defined priorities </li></ul></ul>
  7. 7. Size-Up <ul><li>Safety </li></ul><ul><li>Scene </li></ul><ul><ul><li>How does scene look? </li></ul></ul><ul><ul><li>How many patients? </li></ul></ul><ul><ul><li>Where are they? </li></ul></ul><ul><li>Situation </li></ul><ul><ul><li>Additional resources? </li></ul></ul><ul><ul><li>Critical vs non-critical patient? </li></ul></ul>
  8. 8. Initial Assessment (Primary Survey) <ul><li>Find life threats </li></ul><ul><li>If life threat present, CORRECT IT! </li></ul><ul><li>If life threat can’t be corrected </li></ul><ul><ul><li>Support ABCs </li></ul></ul><ul><ul><li>TRANSPORT!! </li></ul></ul>
  9. 9. Primary Survey With critical trauma you may never get beyond primary survey
  10. 10. Airway with C-Spine Control (if MOI dictates) <ul><li>You don’t need a C-collar yet </li></ul><ul><li>Return head to neutral position </li></ul><ul><li>Stabilize without traction </li></ul>
  11. 11. Airway <ul><li>Noisy breathing is obstructed breathing </li></ul><ul><li>But all obstructed breathing is not noisy </li></ul>
  12. 12. Airway <ul><li>Anticipate airway problems with </li></ul><ul><ul><li>Decreased level of consciousness </li></ul></ul><ul><ul><li>Head trauma </li></ul></ul><ul><ul><li>Facial trauma </li></ul></ul><ul><ul><li>Neck trauma </li></ul></ul><ul><ul><li>Upper chest trauma </li></ul></ul><ul><li>Open it, Clear it, Maintain it </li></ul>
  13. 13. Breathing <ul><li>Is air moving? </li></ul><ul><li>Is it moving adequately? </li></ul><ul><li>Is oxygen getting to the blood? </li></ul>
  14. 14. Breathing <ul><li>Look </li></ul><ul><li>Listen </li></ul><ul><li>Feel </li></ul>
  15. 15. Breathing <ul><li>Give Oxygen immediately if: </li></ul><ul><ul><li>Decreased level of consciousness </li></ul></ul><ul><ul><li>? Shock </li></ul></ul><ul><ul><li>? Severe hemorrhage </li></ul></ul><ul><ul><li>Chest pain </li></ul></ul><ul><ul><li>Chest trauma </li></ul></ul><ul><ul><li>Dyspnea </li></ul></ul><ul><ul><li>Respiratory distress </li></ul></ul>
  16. 16. Breathing If you think about giving oxygen, GIVE IT!!
  17. 17. Breathing <ul><li>Consider assisting ventilations if: </li></ul><ul><ul><li>Respirations <12 </li></ul></ul><ul><ul><li>Respirations >24 </li></ul></ul><ul><ul><li>Shallow respirations </li></ul></ul><ul><ul><li>Respiratory effort increased </li></ul></ul>
  18. 18. Breathing If you can’t tell if ventilations are adequate, they aren’t!! If you are wondering whether or not to bag the patient, you should!!
  19. 19. Breathing <ul><li>If respirations are compromised: </li></ul><ul><ul><li>Expose chest </li></ul></ul><ul><ul><li>Inspect front and back </li></ul></ul><ul><ul><li>Palpate front and back </li></ul></ul><ul><ul><li>Auscultate front and back </li></ul></ul>
  20. 20. Circulation <ul><li>Is heart beating? </li></ul><ul><li>Is there serious external bleeding? </li></ul><ul><li>Is the patient perfusing? </li></ul>
  21. 21. Circulation <ul><li>Does patient have radial pulse? </li></ul><ul><ul><li>Absent radial = systolic BP < 80 </li></ul></ul><ul><li>Does patient have carotid pulse? </li></ul><ul><ul><li>Absent carotid = systolic BP < 60 </li></ul></ul>
  22. 22. Circulation <ul><li>No carotid pulse? </li></ul><ul><ul><li>Extricate </li></ul></ul><ul><ul><li>CPR </li></ul></ul><ul><ul><li>Pneumatic Antishock Garment </li></ul></ul><ul><ul><li>Run!!!! </li></ul></ul><ul><li>Survival rate from cardiac arrest secondary to blunt trauma is < 1% </li></ul>
  23. 23. Circulation <ul><li>Serious external bleeding? </li></ul><ul><ul><li>Direct pressure (hand, bandage, PASG) </li></ul></ul><ul><ul><li>Tourniquet as last resort </li></ul></ul><ul><li>All bleeding stops eventually! </li></ul>
  24. 24. Circulation <ul><li>Is patient in shock? </li></ul><ul><ul><li>Cool, pale, moist skin = shock, until proven otherwise </li></ul></ul><ul><ul><li>Capillary refill > 2 sec = shock until proven otherwise </li></ul></ul><ul><ul><li>Restlessness, anxiety, combativeness = shock until proven otherwise </li></ul></ul>
  25. 25. Circulation <ul><li>If possible internal hemorrhage, QUICKLY expose, palpate: </li></ul><ul><ul><li>Abdomen – 2 liters </li></ul></ul><ul><ul><li>Pelvis – 2 liters </li></ul></ul><ul><ul><li>Thighs – 1.5 liter / side </li></ul></ul>
  26. 26. Disability (CNS Function) <ul><li>Level of Consciousness = Best brain perfusion indicator </li></ul><ul><li>Use AVPU initially </li></ul><ul><li>Check pupils </li></ul><ul><ul><li>The eyes are the window of the CNS </li></ul></ul>
  27. 27. Disability (CNS Function) Decreased LOC in trauma = Head injury until proven otherwise
  28. 28. Expose and Examine <ul><li>You can’t treat what you don’t find! </li></ul><ul><li>If you don’t look, you won’t see! </li></ul><ul><li>Remove ALL clothing from critical patients ASAP </li></ul><ul><li>Avoid delaying resuscitation while disrobing patient </li></ul><ul><li>Cover patient with blanket when finished </li></ul>
  29. 29. The “Load and Go” Situations <ul><li>Head injury with decreased LOC </li></ul><ul><li>Airway obstruction unrelieved by mechanical methods </li></ul><ul><li>Conditions resulting in inadequate breathing </li></ul><ul><li>Shock </li></ul><ul><li>Conditions that rapidly lead to shock </li></ul><ul><ul><li>Tender, distended abdomen </li></ul></ul><ul><ul><li>Pelvic instability </li></ul></ul><ul><ul><li>Bilateral femur fractures </li></ul></ul><ul><li>Traumatic cardiopulmonary arrest </li></ul>
  30. 30. Rapid Trauma Assessment <ul><li>DCAP-BTLS </li></ul><ul><ul><ul><li>D - Deformities </li></ul></ul></ul><ul><ul><ul><li>C - Contusions </li></ul></ul></ul><ul><ul><ul><li>A - Abrasions </li></ul></ul></ul><ul><ul><ul><li>P - Punctures/Penetrations </li></ul></ul></ul><ul><ul><ul><li>B - Burns </li></ul></ul></ul><ul><ul><ul><li>T - Tenderness </li></ul></ul></ul><ul><ul><ul><li>L - Lacerations </li></ul></ul></ul><ul><ul><ul><li>S - Swelling </li></ul></ul></ul>
  31. 31. Initial Assessment <ul><ul><li>A blood pressure or an exact respiratory or pulse rate is NOT necessary to tell that your patient is critical !!!!! </li></ul></ul>
  32. 32. Initial Assessment <ul><ul><li>If the patient looks sick, he’s sick!!! </li></ul></ul>
  33. 33. Initial Resuscitation <ul><li>Treat as you go! </li></ul><ul><li>Aggressively correct hypoxia and inadequate ventilation. </li></ul><ul><li>Control external blood loss. </li></ul>
  34. 34. Initial Resuscitation <ul><li>Immobilize C-spine ? MOI (rigid collar) </li></ul><ul><li>Keep airway open </li></ul><ul><li>Oxygenate </li></ul><ul><li>Rapidly extricate to long board </li></ul><ul><li>Begin assisted ventilation with BVM </li></ul><ul><li>Expose </li></ul><ul><li>Apply and inflate PASG </li></ul><ul><li>Transport </li></ul><ul><li>Reassess and report in route </li></ul>
  35. 35. Initial Resuscitation Minimum Time On Scene Maximum Treatment In Route
  36. 36. Detailed Exam (Secondary Survey) <ul><li>History and Physical Exam </li></ul><ul><li>You WILL get here with MOST trauma patients </li></ul><ul><li>Perform ONLY after initial assessment is completed and life threats corrected </li></ul><ul><li>Do NOT hold critical patients in field for detailed exam </li></ul>
  37. 37. Physical Exam <ul><li>Head to Toe, organized approach </li></ul><ul><li>Every patient, same way, every time </li></ul><ul><li>Top to bottom; near to far, front & back </li></ul><ul><li>Look--Listen--Feel </li></ul>
  38. 38. History <ul><li>Chief complaint </li></ul><ul><ul><li>What PATIENT says problem is </li></ul></ul><ul><ul><li>Not necessarily what you see </li></ul></ul>
  39. 39. History <ul><li>A = Allergies </li></ul><ul><li>M = Medications </li></ul><ul><li>P = Past medical history </li></ul><ul><li>L = Last oral intake </li></ul><ul><li>E = Events leading up to incident </li></ul>
  40. 40. Definitive Field Care Performed ONLY on stable patients
  41. 41. Definitive Field Care <ul><li>Stable patients can receive attention for individual injuries before transport </li></ul><ul><ul><li>Bandaging </li></ul></ul><ul><ul><li>Splinting </li></ul></ul><ul><li>Reassess carefully for hidden problems </li></ul><ul><li>If patient becomes unstable at any time, TRANSPORT </li></ul>
  42. 42. Reevaluation <ul><li>Ventilation and perfusion status </li></ul><ul><li>Repeat vital signs </li></ul><ul><li>Continued stabilization of identified problems </li></ul><ul><li>Continued reassessment for unidentified problems </li></ul>

×