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Trauma Assessment
FEBRUARY 2014 CONTINUING EDUCATION
SILVER CROSS HOSPITAL EMS SYSTEM
ERIKA BALL, RN, BSN

Objectives

Review of mechanisms of injury.

Understanding extremity trauma and amputation;
prehospital treatment and protocol review.

Care of the patient with chest and abdominal
trauma. Review of structures and potential
complications associated with injury.

Review of SMO Code 72 for Decompression of
Tension Pneumothorax
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Phases of Trauma

Pre-event
 Injury
 Not

prevention
usually accidental
Event
 Interact
with people, demonstrate
professional attributes
 Act
as mentor, demonstrate good safety
practices
Phases of Trauma

Post-event
 Optimal
patient care
 Appropriate
 Treat
clinical decisions
patient
 Continues
until patient delivery to ED,
complete report
Trauma Systems

Parts
 Injury
prevention
 Prehospital
care
 Emergency
department care
 Interfacility
 Definitive
 Trauma
transport (if needed)
care
critical care
 Rehabilitation
 Data
collection, trauma registry
Trauma Systems

Trauma center
 Categories
 Level
I
 Regional
resource center
 Specialized
 Level
services (Burn ICU)
II
 Comprehensive
trauma care
 Not
all resources in level I are
immediately available
 Research
not essential component
Trauma Systems

Trauma center
 Categories
 Critical
access
 Communities
without level I or II
 Provide
evaluation, resuscitation,
operative intervention for
stabilization
 Non-designated
 Rural,
remote areas
 Provides
to level I
initial stabilization, transfer
Trauma Systems

Transport considerations
 Time
 Single
most important factor
 Golden
 Do
period
not sacrifice care for speed
 Platinum
 Most
10 minutes
appropriate facility may not be
closest
Trauma Systems
 Transport
Ground
Use
considerations
transportation
if “reasonable” time
Generally
within 30 minutes
Protocols
may alter time frame
Trauma Systems

Transport considerations
 Aeromedical
transportation
 When
time critical to patient condition
 Scene
times extended from extrication
 Road,
traffic conditions seriously delay
access to definitive care
 Critical
care personnel above ground
ambulance training needed
Trauma Assessment
Process
 Scene
Size-Up
 Primary Survey
 Decision for transport, A B C
interventions
 Reassessment and continued
exam
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Scene Size-Up

PPE

Scene safety

Triage/ number of patients (need for
START Triage?)

Help and equipment needs
assessment

Determine Mechanism of Injury
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 Blunt
Mechanism of
injury:
Common
Trauma Injuries
 MVC
 Pedestrian
motion injuries
 Bicycle
 Falls
 Penetrating
What are the
predictive injury
patterns
associated with
these incidents?
 Firearms,

shrapnel, posts
Burns


Drowning
Remember: these are
considered trauma!
BLUNT TRAUMA
Motor
Vehicle
Collision
MVC
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
What are the mechanisms?

Look at the impact locations:
 Front-end
 Side
 “quarter
panel” = potential for
rotational injuries
 Rear-end
 Rollover
 Crush
(under a semi)
Blunt Trauma: MVC
 Machine
 Body
collision
collision
 Organ
collision
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Blunt Trauma: MVC

Vehicle collisions
 Frontal
(head-on) impact
 Down-and-under
 Occupant
 Moves
 Knee
pathway
continues forward
downward in seat
– primary impact point
– Dislocated knee, torn ligaments, knee joint
dislocation
 Tibia
 Popliteal
artery lies behind knee, possible blood clot
impact – Fracture, hip dislocation, pelvic
fracture, acetabular fracture, blood clots, vascular injury
 Femur
 Injuries
may be subtle
Blunt Trauma: MVC


Side Impact:

Head injuries

Cervical spine injury

Pneumothorax/ hemothorax/ tension pneumo

Splenic or liver injury

Pelvic injuries

Extremity injury

Aortic Laceration
Rotational Injury

C-spine injury

Vascular tears
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Blunt Trauma: MVC
This horizontally
oriented skull
fracture was a
result of a side
impact when the
side of the
driver's head
impacted a tree
as the vehicle
slid to a stop
against the tree.
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MVC: What mechanisms of
force would injure the
spleen?
Side, Steering wheel, restrained passenger,
unrestrained hitting seat or dashboard
Spleen injury
Patient has B/P of 70/palp with no rigid
abdomen or distension…
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Note the AMOUNT of blood that lurks
within a spleen injury…(you may need to click play)
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Blunt Pelvic Injury
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What else is BLUNT
trauma?
 Baseball
 Fall
bats, sports injuries
from height
 Ejection
from moving vehicles
(motorcycle, ATV, horses,
bicycles, snowmobiles)
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Blunt Trauma: Pedestrian

Causes fractures of long bones [arms and legs],
and causes fractures of spine, pelvis, and
vertebrae

Often causes internal injuries that may be severe

Commonly causes head injuries in adults and
children

Pneumothorax common in this injury

Two mechanisms of injury:

Vehicle hitting body

Secondary injuries from impact with ground
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Pedestrian
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Pedestrian Trauma

Look for the impact locations on the
vehicle.

The height of the person can also
immensely affect the patient’s injury
patterns (for example, children are
lower at bumper level).

Be aware if the vehicle stopped, or did
it continue in it’s path causing tertiary
crush injuries?
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Bicycle Injuries

Similar to pedestrian versus auto, have
several potential impact sites and
multiple system injuries
 Did
they have a helmet on?
 Speeds of bicycle?
 Were they struck by a vehicle?
 Surface of landing?
 Did they hit anything during fall? (trees,
signposts, other bicyclists)
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Blunt Trauma: Falls

Vertical deceleration

You must determine the following:
 Distance
the person fell
 What
part of the body they landed on
(head, feet first, back)
 Did
they strike anything on the way down?
 What
 All
surface did they land on?
of these are determinants for their
injury patterns
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Trauma: Penetrating Injuries
 High
or low velocity
 Firearms are high velocity
 Determine all wounds involved
 NEVER
document ballistics as
“entry” or “exit” ALWAYS
document as “Wound #1” “Wound
#2” etc.
 You could inadvertently place the
location of a murder suspect and
cause them to be released…
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Penetrating Injury: GSW

There are shock waves with a bullet,
damages surrounding tissue

Causes more damage to solid organs: kidney,
liver, spleen.

Not always a straight line in the body- may hit
bone and change direction

Head, thorax, or abdomen should be
transported IMMEDIATELY. Focus on ABC’s,
trauma assessment, then transport.
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Where are the
potential injuries?
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Intestines/ bowel
Vena cava and
Aorta
Mesenteric Artery
(the artery that
supplies blood to
intestines)
Solid organs:
kidneys, liver,
pancreas, spleen
Base of lung
Pelvis and spine
Penetrating Trauma:
Impalement

Basic reminders:
 Leave
object in place with exception
to occlusion of the airway
 Stabilize
 The
object for transport
severity of the situation is
relative to size, force, and location of
object.
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Note the tourniquet…
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Transport decisions… Is the
airway clear?
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Trauma : A Short
Burn Care Review
 Remember:
 Transport
 Be
burns are a trauma!
to a trauma center
aggressive with airway control
 Assessment
for soot on face,
nose, and hands.
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Burns

Basic review of burn care:

Determine severity

Begin trauma assessment

AIRWAY! AIRWAY! AIRWAY!

Breathing

Circulation

Remove burning source

Cool burn with clean water, (dry if >20% BSA) no
longer than two minutes to avoid hypothermia

Patient is at risk for hypothermia, use precautions
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Trauma:
A Short Drowning Review

150 ml is all it takes to cause profound
hypoxia (ITLS, 2008)

Rapid evaluation and management of
ABC’s

C-spine considerations

Rapid initiation of CPR

Cold water does not indicate death,
remember “warm and dead”
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Trauma Assessment Review
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So here we go…
head-to-toe
Airway/C-spine

While repositioning airway/doing
airway assessment, maintain c-cpine.

Delegate someone to do this or hold cspine so the primary assessor can do
the head-to-toe
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ASSESS AVPU
Alert
Verbal
Pain
Unresponsive
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Airway:
Patent or non-Patent?

Readjust the airway

Do they need suction: teeth, blood,
vomit?

Are they maintaining an airway or do
you need to get an adjunct or intubate?

Make these decisions then move to…
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Breathing

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Are they breathing?
 No?
Begin assisted ventilations
 Yes?
Assess the rate and quality.
 Is
the rate under 12? ASSIST
VENTILATIONS
 Is
the rate over 30? Suspect shock and
make load-and-go decision.
 Quality.
 Yes?
Are they shallow or abnormal?
ASSIST VENTILATIONS
All of these are within normal limits,
place on NRB and move to…
CIRCULATION
 Do
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they have a pulse?
 No?
Begin CPR
 Yes?
Note rate, skin color, and any
hemorrhaging.
Hemorrhaging
 Yes?
 No?
or bleeding profusely?
Control bleeding
Assess skin and need for fluid bolus
 Keep
in mind the need to start 2 large-bore IV
or IO while enroute to Trauma center

If circulation is addressed, move to…
Trauma Assessment
 Head

injury?
Contusions, lacerations?
 Does
the patient have facial injury?
 If
yes, do NOT use nasopharyngeal
airway.
 Signs
of facial fractures, CSF from the
nose or ears, blood from the ears
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Trauma Assessment
 Neck

wounds?
Stepoff on the posterior cervical
spine? Trachea assessment…
midline?
 Place
patient in Cervical collar
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Trauma Assessment

Chest injury?
 Wounds,
gunshots, penetrations, bruising
(seatbelt?)
 Flail
chest
 Sucking
chest wound?
 Treatment?
3
sided occlusive dressing
 Muffled
heart tones? Tamponade?
 Tension
pneumothorax? Decompression
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Sucking chest wound
(you may need to click play)
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Assessment Finding:
Beck’s Triad

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In cardiac tamponade a narrow pulse pressure
is regularly observed.
 The
cardiologist, Claude Beck, who was a Professor
of Cardiovascular Surgery first identified the triad of
medical signs which was later termed “Beck’s Triad.”

Beck’s Triad (in basic terms):
 1.
Distended Neck Veins;
 2.
Muffled Heart Sounds;
 3.
Hypotension.
Assessment Finding:
Tension Pneumothorax
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
Created from blunt or penetrating trauma.

“Collapsed” lung that causes an increase in
pressure in the chest (intrathoracic pressure)

This pressure pushes on the vena cava,
restricting the blood return to the heart.

Also creates pressure on intact lung, making
the situation worse
Assessment Finding:
Tension Pneumothorax

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Symptoms of tension pneumothorax:
 Dyspnea
(difficulty breathing)
 Absent
lung sounds on affected side
 Anxiety
(because of decreased O2)
 Tachypnea
 JVD
(distended neck veins)
 Respiratory
 Loss
distress and cyanosis
of radial pulse
 Tracheal
deviation (often a late sign of this condition)
Assessment Finding:
Tension Pneumothorax
 Needle
decompression: this will
be covered in the skill of the
month
 Emergent
life saving skill not to be
delayed until transport.
 Find
the S/S perform the skill
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Trauma Assessment:
Abdomen

Check for wounds/ bruising/ objects

Tenderness

Rigidity

Pulsations

Check all four quadrants

Are they pregnant?

Move on to…
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Trauma Assessment:
Pelvis
 Do
NOT rock the pelvis to check
it!
 This
can cause further injury and
bleeding
 3-4
Liters of blood loss potential
into the abdominopelvic cavity
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Trauma Assessment:
Pelvis Assessment
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Inward pressure one time, and down on the pubic symphysis
Trauma Assessment:
Extremity Trauma

Open or closed trauma
 Both
have potential for bleeding
 Sharp
bone fragments can cause damage
to surrounding vessels and tissue causing
bleeding

Closed femur fracture can cause 1 liter of
blood loss

Assess need for traction splinting
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Trauma Assessment:
Extremity Trauma


Assessment of PMS

Perfusion

Movement

Sensation
Also called CSM

Circulation

Sensation

Movement
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Extremity Trauma:
Amputations





Potential for life threatening blood loss
Blood loss is quickly minimized with
pressure/ tourniquet
Small parts should be covered with gauze
and placed in a bag. Place bag in
ice/water mix and transport.
Reassurance of patient’s well-being.
Psychological distress may be immense.
DO NOT DELAY TRANSPORT TO WAIT FOR LIMB
RECOVERY
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Extremity Trauma:
Amputations From Blast Injury
Jeff Baumann,
Boston
Marathon
victim
Blast
amputation
with exposed
tibia
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Extremity Trauma:
Amputations From Blast Injury

Parts are generally non-recoverable

Focus on ABC’s

Don’t let the gore become a distraction

Maintain C-spine

Remember, there are three impacts from blast injuries:

Primary air impact. Effects on hollow structures- lung,
bowel, and eardrums.

Secondary blast from shrapnel. This is the zone where
limbs are amputated, although the primary blast is also
responsible.

Tertiary blast from hitting ground.
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Extremity Trauma:
Amputations From Blast Injury
 Tourniquet
 This
bleeding limbs
saved MANY lives in Boston.
Bystanders and available medical
personnel applied tourniquets using
belts and clothing fragments
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He recovered and has prosthetic limbs.
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Extremity Trauma:
Compartment Syndrome


Bleeding and swelling within the enclosed
compartment of the limbs (generally, but this
can happen with the abdomen as well)
Caused by crush injuries, fracture (open or
closed), and compression of limb for
extended period.



Blunt force injury to a muscle can also be a
cause of compartment syndrome
May loose pulse, sensation, and movement
Severe pain is an early symptom
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Skill/SMO of the month,
Needle decompression
Code 72
Equipment

Antiseptic

2-3 inch, large-bore (10-14#)catheter

One-way valve if available

Chest tape for stabilization
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Decompression location
2nd intercostal
space
Mid-clavicular
line
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Needle Decompression Pearls

If the patient is lying supine, the
proper site to decompress for trauma
is 2nd or 3rd ICS in the Mid-clavicular
line

If the person is in a sitting position, the
proper site is in the 4th or 5th ICS in the
Mid-axillary line

This is to protect the lung tissue from
being penetrated by the initial needle
introduction into the pleural space
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Skill and SMO of the month
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Thank you for your time and attention!
Questions or comments?
Erika Ball, RN, BSN
Silver Cross EMS System Educator
815-300-7426
eball@silvercross.org