Aaron Markwith, CCEMTP Valencia College Paramedic Laboratory I All rights reserved. No portion or part of this presentation may be reproduced or edited without prior written permission from the author None of the photos used in this presentation are the property of the author. All pictures were obtained from images.google.com and are the property of their respective owners 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.