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Assessment andManagement3

Lesson

Prehospital Trauma Life Support

Copyright 2003, Elsevier Science (USA). All rights reserved.

PROVIDER COURSE

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Objectives

Discuss the importance of scene assessment

Identify components of the primary survey

Differentiate between critical and noncritical

patients Defend the need for early transport of critical

patients

Describe when to perform a secondarysurvey


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Its mid-January and you have been dispatched

to a multi-vehicle crash on the Interstate. Initial

reports are that there are multiple patients and

a fuel tanker is involved.

When does your scene assessment begin?


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What are the components of scene assessment?


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Scene Safety

Ensure safety of rescuers and patients

Threatening situations may include:

Fire Traffic Electrical lines Weapons

Hazardous materials Environmental

Blood and body fluids conditions

Can you think of any other hazards?


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Scene Situation

What really happened?

What are the kinematics?

How many patients involved? Ages?

Additional resources needed?

How will patients be transported?


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Your patient is the 32-year-old female

unrestrained driver who is found slumpedover in the vehicle. She has no obvious

external hemorrhage, is breathing rapidly,

and is mumbling inappropriate words.

What do these findings suggest?

How should you assess this patient?


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Standard Precautions

Gloves Eye protection

Masks

Gowns

Inappropriate handling/disposal of

contaminated sharps and other items


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Patient Assessment

Primary survey

Treat as you go

Resuscitation

Secondary survey Definitive care in the field


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Primary Survey

A irway/cervical spine

Breathing/ventilation

Circulation

Disability

Expose/Environment


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Airway

Manual stabilization of

the cervical spine

How is the airwayassessed?

What interventions may be

needed?


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Circulation

Assess for and control external hemorrhage Assess perfusion:

Pulse Skin

- rate - color

- quality - temperature

- regularity - moisture

- location - capillary refilling time


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Disability

Level of consciousness GCS score can range from 3 to 15

Eyes

Verbal

Motor

Pupils

Reporting total GCS score instead ofreporting the individual components


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Glasgow Coma Scale

Eyes Open your eyes. Nailbed pressure or axillary tissue squeeze

Verbal What happened to you?

Add T to score if intubated

Motor

Hold up two fingers Nailbed pressure or axillary tissue squeeze


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Glasgow Coma Scale

Eye Opening Spontaneous 4To Voice 3

To Pain 2

None 1

Verbal Response Oriented 5

Confused 4

Inappropriate Words 3Incomprehensible Words 2

None 1

Motor Response Obeys Command 6

Localizes Pain 5

Withdraw (pain) 4Flexion (pain) 3

Extension (pain) 2

None 1


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Expose/Environment

Expose patient as environment allows toassess for other life-threatening conditions;

then preserve/maintain body heat

Life-threatening conditions missed because of

failure to adequately expose the patient

Failing to preserve body heat and to considerenvironmental conditions


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Breathing

Airway

Kinematics

Circulation

Disability

Expose/

Environment

Simultaneous Assessment


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Decision Making


3-19

Trauma-related incident

Scene assessment

Primary Survey

Life threatening or multisystem injuries

NoYes

Initiate rapid transport

Reassess

Secondary survey

Secondary survey

Reassess

Manage injuries as appropriate

Initiate transport

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Critical Trauma Patient

You may never get past the primary survey if

the patients status is critical

Failing to recognize a critical trauma patient during

the primary survey

Failing to complete a secondary survey after life-

threatening conditions are managed


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Critical Trauma Patient

Inadequate or threatened airway Impaired ventilations

Hemorrhage

Shock

Abnormal neurological status

Most penetrating trauma

Amputation or near-amputation

Trauma combined with complicating factor


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A 16-year-old loses control of his bicycle ongravel. Your patient is found on the side of

the road holding his right wrist. Multiple

abrasions are noted on his face and upper

extremities. The scene is safe.


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Primary Survey

A-PatentB - Normal; BS clear

C - Minor bleeding from chin laceration; radial

pulse normal; skin warm, pink, and dry

D - GCS score 15

E - Deformity noted to right wrist

How do you proceed?


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Secondary Survey

Vital signs

AMPLE history

Head-to-toe exam

Performing a secondary survey on a critical patient

prior to initiating resuscitation

Failing to complete a secondary survey on a

noncritical patient


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Head-to-Toe Exam

Systematic and complete:

Observation

What do we lookfor? Auscultation

What do we listen for?

Palpation

What do we feelfor?


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Definitive Care in the Field

Packaging Spinal immobilization if indicated

Splint musculoskeletal injuries

Dress wounds


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Transportation

Closest appropriate facility In general, bypass closest facility to reach

trauma center

Receiving facilities should be determinedby local protocol

Mode

GroundAeromedical


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Trauma Center Candidates

Triage to trauma centers determined by:

Physiologic criteria

Anatomic criteria

Mechanism of injury

Preexisting conditions

Follow local protocol


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Reassessment

How frequently should we reassess?

What should we reassess?

Failing to recognize the development of life-

threatening conditions in a previously

noncritical patient


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Pain Management

Administering analgesia to a critical

trauma patient

Withholding analgesia from a trauma

patient with an isolated injury who

complains of pain


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Communication

What information should be communicated

to the receiving facility?


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Notify receiving facility

as early as possible

Trauma team activation

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Documentation

Well-written narrative Pertinent findings

Care provided

Response to treatment

A legal document

QA/QI

Failing to document the reasons for delay

in transport of critical patients


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Triage

Multiple patients with adequate resources Treat most critical patients first

Multiple patients with inadequate resources

Treat those with the greatest likelihood of survival

first

Be familiar with local disaster plan

Use Incident Command System


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Summary Perform scene assessment

Initiate treatment for life-threatening

conditions when identified during primary

survey

Prompt transport of critically injured patientsto closest appropriate facility

Complete assessment and definitive care of

noncritical patients

Communicate and document key

information

Copyright 2003, Elsevier Science (USA). All rights reserved.3-35

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