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