Aaron Markwith, CCEMTP Valencia College Paramedic Laboratory I
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Scene Size Up
Initial Assessment
Focused Trauma Assessment
Rapid Trauma Assessment
Ongoing Assessment
Cannot be emphasized enough ◦ Priorities 1. Yourself 2. Your Crew 3. The Patient 4. Bystanders
Don’t let anything deter you from that.
Don’t be a hero
BSI ◦ PPE Is this a Trauma or a Medical patient? ◦ If medical, determine the nature of illness (NOI)
◦ If Trauma, determine the mechanism of injury (MOI) Check the number of patients ◦ Mass Casualty Incident (MCI Establish Command
Call for more units
Triage patients Ensure you have adequate resources for your patient. ◦ Fire Department Extrication Multiple patients HAZMAT Manpower Roadway safety
◦ Police Ensure scene safety Violent bystanders/patient Forced entry to residence/business
Determine the Age/Sex of patient
Position Found ◦ Skin color
Work of Breathing
Level of Anxiety
If trauma is suspected, assign someone to hold c-spine IMMEDIATELY. Holding c-spine is a critical intervention, if it is not done IMMEDIATELY, you will fail your scenario First, check how responsive the patient is:
◦ Alert If alert, are they oriented? Person Place Time Event
If the patient is only alert 3 of the 4, you would say he is A&O x 3.
If he was alert to 2 of the 4 then he is A&O x 2 etc. Alert to Verbal Stimuli ◦ Make a loud noise
◦ Clap your hands in front of the patient’s face
◦ Determine the reason for this level of consciousness Alert to Painful Stimuli ◦ Sternal Rub Make a fist and firmly rub back and forth on the patient’s sternum
◦ Pen Test Take your pen and push it hard on the patient’s knuckles
Unresponsive ◦ Patient does not respond to ANYTHING you try Used to help quantify AMS
The highest score you can get is a 15
The Lowest Score you can get is a 3 ◦ “A rock gets a 3”
Broken down into 3 sections ◦ Eyes (1-4)
◦ Verbal (1-5)
◦ Motor (1-6) Does the patient have their eyes open when you walk up? ◦ Score 4
Does the Patient open their eyes to verbal stimuli? ◦ Score 3
Does the patient open their eyes to painful stimuli? ◦ Score 2
The patient will not open their eyes at all, regardless of stimulation. ◦ Score 1 Does the patient speak coherently and normally? ◦ Score 5
Is the patient confused or disoriented? ◦ Score 4
Wind are puppies Does the patient use inappropriate words? joy fellow snow ◦ Score 3 boat fell Does the patient just Ugg rthh dohh mumble sounds? ◦ Score 2 quiinnn
Does the patient not speak, nor make any other sounds? ◦ Score 1 Does your patient obey commands? ◦ Score 6
Does the patient localize pain? ◦ Score 5
Does the patient withdraw from pain? ◦ Score 4 Does the patient demonstrate decorticate posturing (bringing arms to the “core”) ◦ Score 3
Does the patient show signs of decerebrate posturing? ◦ Score 2
Does the patient show no signs of movement regardless of stimulation? ◦ Score 1
GCS >8 ◦ Many times a patient with a GCS >8 requires airway protection…in other words, we may need to intubate the patient
Total score ≥ 13 ◦ Minor
Total score = 9-12 ◦ Moderate
Total Score ≤ 8 ◦ Severe
In a conscious patient assign someone to check pulse ◦ Rate Fast or slow
◦ Rhythm Regular or Irregular
◦ Quality Strong or weak Assign someone to check respirations ◦ Rate Fast or slow
◦ Rhythm Regular or Irregular
◦ Depth Deep or Shallow
If the patient is pulseless:
◦ One or two rescuer: Begin chest compressions of 30:2 5 cycles for 2 min
If the patient has AMS and inadequate respirations: ◦ Open airway with head-tilt chin lift Jaw Thrust if trauma suspected
◦ Ventilate 1 breath every 5- 6 seconds
◦ Each breath over 1 second ◦ Attach to 15lpm O2 Don’t delay BVM for O2 Don’t forget O2
◦ Insert airway adjunct Don’t delay BVM for airway adjunct
Oral Pharyngeal Airway (OPA)
Nasal Pharyngeal Airway (NPA
Size by measuring from the corner of the mouth to the angle of the jaw ◦ If it is too big it will obstruct the airway
◦ If it is too small it will block the airway with the tongue
Insert in the mouth inversely or side- ways
As you reach the back of the mouth turn it into place
Contraindications: ◦ Gag Reflex
◦ Alert Patient
NPA ◦ Also called a “Nasal Trumpet”
Size the device by measuring from the tip of the nose to the bell of the ear
Choose the larger of the nares
Lubricate the NPA
Place bevel to the septum ◦ Left nare You will need to twist the NPA once resistance is met to follow the anatomy of the body
Advance until the airway is flush with the nose
Contraindications ◦ Suspected basilar skull fracture
ALWAYS place your patient on Oxygen ◦ It is a critical intervention!
◦ Don’t fail your scenario over this! Nasal Cannula ◦ Used when there is no respiratory distress
◦ 1-6 liters per minute
◦ Can deliver 24-44% FiO2 (Fractional inspired Oxygen) Non-Rebreather Mask ◦ Flow at 10-15 liters per minute
◦ Ensure the reservoir bag remains at least 2/3 full with each breath
◦ Can deliver >90% FiO2
◦ Used with respiratory distress Disability ◦ Obvious disabilities Open fractures, etc.
Expose ◦ Vital to identify life threatening problems CUPS
◦ Critical Emergent transport
◦ Unstable Emergent transport
◦ Potentially Unstable Emergent or urgent transport
◦ Stable Urgent transport
REMEMBER PATIENT CONDITION CAN CHANGE EN ROUTE!
Used when there a non-significant mechanism of injury
The Focused Trauma Assessment for the injured site is the same as the corresponding Detailed Trauma Assessment
From start to finish, the Rapid Trauma Assessment (RTA) should take less than 120 seconds DCAP-BTLS ◦ Deformities ◦ Contusions ◦ Abrasions ◦ Punctures/Penetrations ◦ Burns ◦ Tenderness ◦ Lacerations ◦ Swelling
DCAP-BTLS ◦ Assess for blood or fluid in the eyes (hyphema)
◦ Assess pupils If unequal suspect head injury and transport EMERGENTLY
◦ Assess for blood or fluid in the ears
◦ Assess for blood or fluid in the mouth DCAP-BTLS ◦ Check for Tracheal Deviation Assess lung sounds
If life threatening emergency identified, treat on scene
◦ Check for jugular vein distention
◦ Feel for cervical step-down Whether it is felt or not, apply c- collar if cervical trauma is suspected
C-Collar is a Critical Intervention PRIOR to log roll DCAP-BTLS ◦ Check for subcutaneous emphysema Free air under the skin
Sign of punctured lung
Feels like crushed Styrofoam under the skin DCAP-BTLS ◦ Listen the Lung sounds
If pleural decompression is required use 14g 2-4 inch catheter and decompress on 2nd to 3rd intercostal space Only decompress a Tension Pneumothorax
◦ TIC Tenderness Make note of it, nothing to do as far as interventions
Instability Secure with bulky dressing if flail segment noted
Crepitus Secure with bulky dressing if flail segment is noted Observe for paradoxical motion
DCAP-BTLS
◦ One quick squeeze on the abdomen
DCAP-BTLS ◦ TIC Tenderness Observe and report
Instability Stabilize on LBB
Crepitus Stabilize on LBB
◦ Suspect 2 liters of blood loss from a Fractured Pelvis
DCAP-BTLS
◦ Only treat life threatening emergencies on scene
◦ Check Babinski reflex Normal toes flex forward
Abnormal (positive Babinski) toes flare outward (sign of increased ICP)
DCAP-BTLS ◦ Only treat life threatening emergencies on scene Ensure C-Collar in place!
Carefully log roll the patient
DCAP-BTLS Move patient to ambulance ◦ Reassess the ABC’s
◦ Get the first set of V/S Blood Pressure
Heart Rate
Respiratory Rate
Skin Color
Pupils Attach 3-lead ECG
Establish 2 large bore IV’s ◦ Attached to 2 1,000mL NS bags
◦ Do not necessarily need to run both wide open
Connect SpO2 and EtCO2
DCAP-BTLS ◦ Assess for blood or fluid in the eyes (hyphema) ◦ Assess pupils If unequal suspect head injury and transport EMERGENTLY
◦ Assess for blood or fluid in the ears Halo Test
◦ Assess for blood or fluid in the mouth Check for any other obstructions (i.e. teeth) ◦ Assess for Battle Signs (retroauricular ecchymosis) Sign of a basilar skull fracture…do not use NPA
◦ Assess for Raccoon Eyes (Bilateral periorbital ecchymosis) Sign of a basilar skull fracture…do not use NPA DCAP-BTLS ◦ Difficult to reassess with C-Collar in place Re-Check for Tracheal Deviation Assess lung sounds
If life threatening emergency identified, treat on scene
Re-Check for jugular vein distention If Present, possible Cardiac Tamponade or Tension Pneumothorax
DCAP-BTLS ◦ Re-Check for subcutaneous emphysema DCAP-BTLS ◦ Listen the Lung sounds If pleural decompression is required use 14g 2-4 inch catheter and decompress on 2nd to 3rd intercostal space Only decompress a Tension Pneumothorax
◦ TIC Tenderness Make note of it, nothing to do as far as interventions
Instability Secure with bulky dressing if flail segment noted
Crepitus Secure with bulky dressing if flail segment is noted Observe for paradoxical motion
DCAP-BTLS ◦ Assess for rigidity If rigidity found, transport emergently to ER
◦ Assess for distention If present, emergently transport to the ER
◦ Assess for pulsing masses
◦ Give fluids as needed to keep BP >90mmHg Systolic
DCAP-BTLS ◦ If a fractured pelvis was noted prior, do not push on the pelvis again Duh!
◦ Suspect 2 liters of blood loss from a Fractured Pelvis
◦ Assess BP and give fluids to keep BP >90mmHg Systolic
DCAP-BTLS ◦ Pulse check Dorsalis Pedis Posterior Tibialis
◦ Motor Check to see if patient obeys commands Check equality of strength in legs
◦ Sensation Identify which toe you are touching Check nervous reaction Babinski Reflex DCAP-BTLS ◦ Check Radial Pulse
◦ Motor Grip strength Equal?
◦ Sensation Nervous Reaction
Difficult to do when patient is on LBB
Continually reassess your patient ◦ CAB’s
Reassess the interventions ◦ Response to your medications i.e. recheck a blood sugar Reassess Blood pressure post fluids
Reassess your vital signs ◦ Stable Patient every 15min
◦ Unstable Patient every 5min
Always treat new problems as they arise, remember that the patient condition can change en route!
Remember, a good assessment can be the difference between life and death!
Airway burns: ◦ Make sure you secure the airway as soon as possible with an ETT Singed Nasal Hairs
Burns around the mouth and nose
Prolonged exposure to fire/smoke
Consider Surgical Airways if Necessary
Tension Pneumothorax ◦ HYPOtension BP < 90mmHg Systolic Lack of radial pulse
◦ Difficulty Breathing
◦ Diminished/Absent unilateral breath sounds
◦ Tracheal Deviation
◦ May be used with an open chest wound ONLY AFTER THE OCCLUSIVE DRESSING HAS BEEN “BURPED” Ensure appropriate BSI ◦ Gloves ◦ Eye Protection
Prepare Equipment ◦ Always gather the appropriate equipment prior to beginning the procedure Clean the site with iodine pad ◦ If iodine contraindicated, clean the site twice with alcohol prep
Take a 14g 2-4 inch needle, remove the cap from the back of the needle Identify the landmark If the needle is placed ◦ 2nd intercostal space too medially then you run the risk of ◦ Between the second and puncturing the heart third rib
If a tension ◦ Midclavicular pneumothorax is misdiagnosed then you ◦ Always place the needle ABOVE the third rib, not run the risk of lung beneath the second trauma or creating a pneumothorax Insert the needle until you hear/feel air coming from the needle
Remove the needle and place in the sharps box
Stabilize the catheter with 4x4s and tape
Repeat as necessary ◦ To repeat, go RIGHT NEXT to the initial site Return to RTA Chest Trauma Page The End