Trauma Pt Assessment
Scene Size-up:
BSI/Scene safe
Dispatch MOI/NOI:
Is ALS warranted from dispatch info?
When I first encounter pt does scene jive with dispatch info?
How many pts?
Do I need help:
Do I have any info that indicates need for more people or equipment
When I see pt does someone need to take c-spine control?
Initial Assessment:
Verbalize General Impression:
Skin color
Body position
Alertness
Introduce yourself, Reaffirm with pt CC , Gain permission to treat
State AVPU
Verbalize airway status – Fix if not patent
Verbalize adequate or inadequate breathing – fix if inadequate
Add O2 based on patient presentation – NC or NRB
Verbalize circulation:
Skin Color
Pulse present – Where?
Major bleeding – Is blood sweep needed?
Sick or Not Sick?
Focused Hx and Exam (Responsive and no sig. MOI) OR Rapid Exam (Unresponsive or sig. MOI):
Focused Hx and Exam:
S (OPQRST) AMPLE
Focused Physical exam (Chapter 8 Handout pg. 284) EXPOSE INUJURIES!
Example: Head trauma:Pupils, CSF/Fluid, Signs of Skull Fracture, Busted Facial bones, Airway threats from blood, teeth?
Neck: KNOW
Chest: KNOW
Abd: KNOW
Hip/pelvis: KNOW
Back: KNOW
Extremity Px: DCAPBTLS, Manual Stabilization needed?
Vitals – Don’t forget lung sounds on all patients (Bp can be by palp if needed)
Intervention – Known your interventions down pat!
Examples: Chest Trauma: Sucking chest wound – Occlusive 3 sided dressing, exit wound, lung sounds, JVD or Trachea dev., Rib stability, breathing adequate (ppv?), possible underlying organ involvement, Treat for shock, Backboard, Rapid Tx?
KNOW INTERVENTIONS FOR ALL TRAUMA AREAS!!!
Reassess Tx decision and move or verbalize why you’re not (i.e. not enough people to move pt yet)
OR:
Rapid Exam – See Chapter 8 handout pg. 283 and Skill Drill 8-1: EXPOSE INUJURIES!
Identify and correct life threats:
HEAD: Pupils, CSF/Fluid, Signs of Skull Fracture, Busted Facial bones, Airway threats from blood, teeth?
CORRECT ANY FINDINGS BEFORE NEXT STEP i.e. suction airway
NECK: Quick palp of cervical spine for deform, JVD (indicates what?) Trachea dev. or tugging (indicates what?), open wounds.
CHEST/LUNGS? KNOW LIFE THREATS
ABD: KNOW LIFE THREATS
PELVIS: KNOW LIFE THREATS
EXT: KNOW LIFE THREATS
KNOW INTERVENTIONS FOR ALL ABOVE!!
SAMPLE – May need to get from witness as best as possible
Vitals
Interventions:If life threats handled or not found, do any other immediate intervention: i.e. bandage minor bleeds, backboard, splinting
Reassess Tx decision and move or verbalize why you’re not (i.e. not enough people to move pt yet)
Detailed Physical Exam:EXPOSE INUJURIES!
Per Book - Chapter 8 Handout pg. 298
Vitals
Ongoing Assessment:
Repeat initial Assessment
Verbalize so evaluator knows
Vitals
Repeat Focused Exam
Check Interventions
Still effective?
Any changes?
Short Report
*** IF PATIENT CONDITIONS CHANGES SIGNIFICANTLY AT ANY TIME RETURN TO INITIAL ASSESSMENT!