ASSESSMENT OF THE TRAUMA
PATIENT
2nd Trimester, June 2013 CME
Prepared by Leslie Livett RN, MS
Presence St. Joseph Medical Center
Objectives
• Upon successful completion of this module,
the EMS provider should be able to:
– Understand what the mechanism of injury is and the
information it provides
– Describe assessment and treatment appropriate for the
patient with traumatic insult
• Tension pneumothorax, sucking chest wound, flail chest,
eviscerated organs
– Successfully identify the landmark and perform chest
needle decompression
– Actively participate in trauma scenario discussion
Definition
• Damage to the body caused by an exchange of
energy beyond the body’s resilience.
Epidemiology of Trauma
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Leading cause of death in ages 1-44
3rd leading cause of death for all ages
100,000 deaths/year
60 million injuries/year
Overall Approach
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Anticipate the worst
Never make any assumptions
History and Exam have to make sense
Don’t take short cuts
Document frequently
TEAMWORK
Don’t get distracted with “ugly injuries”
Your Initial assessment findings will determine
how you will proceed
• Caveats in Elderly:
– Loss of Reserve Function
– Assume that every organ has some degree of loss
– Improve outcomes
Trauma System
Mortality is decreased when
The RIGHT patient
Gets to
The RIGHT hospital
In the
RIGHT AMOUNT of TIME
A B C’s of Trauma Care
• Many ways to interpret that
• The original way
A Airway with C-spine
B Breathing
C Circulation
The New Way
A Airway
B Be Careful of the Airway
C Concentrate on the Airway
(An Amusing Variation)
• A Antibiotics
• B Blood Cultures
• C Consults
• A Always
• B Bring
• C Camera
Approach to Trauma
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Challenging
Systematic Approach to Patient Care
Logical & Organized
Mechanism of Injury
General Assessment Pearls
• With restlessness and agitation, you must
consider
– hypoxia,
– shock,
– influence of alcohol and/or drugs
– need to assess for all reasons of
restlessness.
– don’t not just stop when you discovered one cause
– there may be more than one pathology going on at a
time
AIRWAY
• Way back in 1983, studies showed us that NO
Airway or a DELAYED airway was the single
most important cause of mortality in trauma
If you THINK you need an airway ….
YOU DO
Airway Assessment Maneuvers in
Trauma
• Inspection
– Color, contour, symmetry, smell, audible abnormal sounds, obvious
wounds
• Palpation
– Textures, moisture, pulsations, deformities, crepitus, masses,
temperature
• Percussion
– Resonant = normal
– Hyperresonant = more air
– Dull = solid, fluid
• Auscultation
Focused History Physical Exam
• As you approach: OBSERVE
– Level of Consciousness
– Appearance
– Restlessness
– Distress/Pain
– Hemorrhage/Gross Deformities
– Unusual odors
– Kinematics
Airway & C-Spine
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Access
Assess
Maintain
Cervical Spine Control
Airway Compromised
• What are some etiologies of a compromised/
obstructed airway in trauma?
Airway Compromised
• Discuss: What are some causes of a
compromised/ obstructed airway in trauma?
Airway Assessment
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Observe for Respiratory effort
Symmetry
Accessory muscles
Audible sounds
– What should ventilations
sound like?
• Ability to talk
• Impaired laryngeal reflexes
Airway Intervention
• Position Appropriately
• Reposition Mandible
– Chin lift, jaw thrust
– DO NOT
• Hyperextend or Hyperflex
• Remove Debris/Suction
• Maintain with Adjuncts
Airway Adjuncts
• Nasopharyngeal if awake
• Oropharyngeal if unconscious/no gag
• Rescue:
– BVM, Intubation,King LTS-D,
Airway Adjuncts
• Lower Airway
– Needle Cricothyrotomy
– Quick-trach
Need to secure
your airway &
always reassess!
Spine Precautions
• Manual in-line stabilization
– Maintain axial alignment
• Apply c-collar
• Provide lateral immobilization
Airway Caveats in special
populations
• Obese
– Sleep apnea, elevate head of bed, difficult access
to airway
• Elderly
– Spine/arthritic changes
– Dental appliances
Breathing
• Inspect
– Expose the chest
• Palpate
• Percussion
• Auscultate
Breathing Inspect
RATE, PATTERN, DEPTH, EFFORT
• Appearance
• Symmetry
• Signs of past trauma
• Accessory muscles
• Speech
• Jugular veins
• Cough
Breathing Palpate
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Pain, point tenderness
Deformity
Chest wall expansion
Mobility
Crepitus
Skin temp/moisture
SQ emphysema
Tactile fremitus
Position of the trachea
Breathing Percussion
• Hyperresonance
– Pneumothorax or emphysema
• Dull
– Blood from hemothorax
Breathing Auscultate
• Perform immediately if in distress
– Audible
– Listen
• Ominous sound = silence
• Tissue mismatch: reflects sound away
Breathing Auscultate
• Where to listen?
– Epigastrium (first after intubation)
– Anterior
– Lateral
– Posterior
Breathing Compromise
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Dyspnea
Bradypnea: weak/shallow
Tachypnea
Cough
Diminished or absent breath sounds
Signs of chest trauma
Increased effort using accessory muscles
SQ emphysema
Unequal pulmonary excursion
Hypoxia/cyanosis
Restlessness
Breathing Intervention
• Pulse OX (SpO2)
• Oxygen (NRB)
Breathing Life Threats
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Tension Pneumothorax
Open Pneumothorax
Flail Chest
Massive Hemothorax
Needle Decompression
• Landmarks anterior approach
– 2nd intercostal space in the midline of the
clavicles
– Place prepared flutter valve needle over
the top of the rib
• Avoids potential injury to vessels and
nerves that run along the bottom of the
rib
Quick Way to Find 2nd ICS
• Feel for the top of the sternum
• Roll your finger tip to the anterior surface at the top
of the sternum
• Feel the little bump near the top of the sternum
– This bump is the Angle of Louis
• From the Angle of Louis slide your fingers angled
slightly downward toward the affected side following
the rib space
– You are automatically in the 2nd ICS
• Identify the midline of the clavicle
– The midline is more lateral than persons realize and
usually runs in line with the nipple
Alternate Method to Find 2nd Intercostal
Space
• Palpate the clavicle and find the midline
– The midline is farther out (more lateral) from the sternum
than most persons realize
• Move your finger tips under the clavicle into the 1st
intercostal space
– 1st rib is under the clavicle and is not palpated
– Spaces identified for the numbered rib above the space
• Feel for the firm 2nd rib and palpate the soft space
below the rib
– This is the 2nd ICS
Needle Decompression
• Find your own 2nd ICS
• Now find your neighbor’s 2nd ICS
– Use both methods to find the landmark and
decide which is easiest for you
• Documentation
– To include signs and symptoms
– Size of needle used (length and gauge)
– Site needle inserted into
– Response from the patient
Equipment
• Long needle (preferably 2-3 inch) and large bore
needle (preferably 12-14G)
• Flutter valve
– Not required by system, but can be helpful
– Commercial devices, or finger from a glove
• Cleanser to prepare skin
• Method to secure needle in place
– Skin will most likely be diaphoretic
– Tape may not stick
– May need to maintain manual control of needle
Skin Preparation
Midline of
clavicle
2nd ICS
Angle of
Louis
Inserting the Needle
• Remove proximal end cap
from needle
– Will be able to hear trapped air escaping
• Needle inserted over top of rib
– Once hiss of air heard continue to advance
catheter while withdrawing stylet
• Stabilize catheter as best as possible
• Patient should symptomatically improve
– Do not expect to hear improved breath sounds;
takes time for the lung to reexpand
Case Study #1
• EMS is called to the scene for a 52 year-old male with
c/o sudden onset dyspnea with pain between his
shoulder blades while watching TV at home. The
patient is agitated, short of breath, with increased
respiratory rate and SaO2 of 89%.
• Further assessment reveals decreased breath sounds
on the right and clear on the left
• Vital signs: 98/62; HR 118; RR 32 and shallow
• Your impression & intervention plan?
Case Study #1
• Spontaneous tension pneumothorax
– They don’t all develop from trauma
• Begin supplemental oxygen support via nonrebreather, cardiac monitor, preparation for IV
BUT
• Quickly prepare for needle decompression while the
above are being prepared
– Patients with a tension pneumothorax can’t wait and will
deteriorate without needle decompression
Sucking Chest Wound
• Most common with penetrating wounds
• Free passage of air between the atmosphere
and pleural space if the open wound is at least
2/ rd the size of the diameter of the trachea
3
– Size of trachea about the size of pt’s 5th finger
• Air is drawn into the chest cavity
• Air replaces lung tissue
• Lung collapses
Sucking Chest Wound
• Severe dyspnea
• Open chest wound
– Check anterior, posterior, axilla areas
• Frothy blood at wound opening
• Sucking sound as air moves in and out
• Tachycardia with hypovolemia
Treatment Sucking Chest Wound
• Immediate treatment is to seal the opening
– May start by placing a gloved hand over the
wound
– When able, place an occlusive dressing, taped on
3 sides, over the wound
• Wound now converted to a closed
pneumothorax
• Monitor for signs of tension pneumothorax
– May need to lift a corner of the dressing to release
trapped air via burping dressing
Flail Chest
• 3 or more adjacent ribs broken in 2 or more places
– Segment becomes free with pardoxical chest wall motion
during respirations
– Paradoxical movement more evident after the muscles
splinting the flail segment fatigue
• Usually takes a tremendous amount of blunt trauma
to cause a flail chest
• Often present will be associated severe underlying
injury (ie: pulmonary contusion)
• Respiratory volume reduced and respiratory effort
increased
Treatment Flail Chest
• Place patient on the injured side (may not be possible to
do this in the field based on mechanism of injury)
• High flow oxygen – nonrebreather mask
– Monitor for need to assist ventilations via BVM to
deliver positive pressure ventilations
• Evidence of underlying pulmonary injury
• Effort and fatigue
• Pulse oximetry
• EKG monitoring
– Tremendous amount of force is delivered to the
chest wall and cardiac injury is highly likely as a
result
Breathing Caveats
• Elderly:
– Pulmonary system is the leading cause of posttraumatic complications
– Consider the need to intubate
– Caution to over-correct patients with COPD
– But Never withhold oxygen to any patient who needs it
Breathing Caveats
• Morbidly Obese:
– Difficult assessment
– SpO2 monitoring
– CO2 retention may occur often
– Tension Pneumo might need 10g (longer than 14g)
Circulation Assessment
• Pulses
– Radial: B/P 80-90 mm Hg
– Femoral: B/P 70mm Hg
– Carotid: B/P 60mm Hg
– Rapid, thready, >120 = probable shock
Circulation Assessment
• Perfusion
– Mental status
– Skin color/temp of extremities
– BP/secondary survey
– Quality of the peripheral pulse
Circulation Assessment
• Skin Color, Temperature, & Moisture
– Vasoconstriction = shock
• Cap Refill < 2 sec
• Level of Consciousness
– Indicator of central perfusion
• Bleeding
– Location, type, amount, & rate
Circulation Life Threats
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PEA
Cardiac Tamponade
Shock
Massive Hemothorax > 1,500 ml
Circulation Resuscitation
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CPR, if needed
Control bleeding
IV access
Fluids
EKG monitoring
MAST Pants/PASG no longer required on
ambulance by IDPH
FLUIDS
• Adults
– “Fill the Tank”
– Not always effective… filling tank with water will not
allow engine to run
– But sometimes it’s all we have
– Bolus isotonic fluid to maintain effective
systolic BP
• Pediatrics
– 20 cc/Kg then maintenance
Circulation Caveats
• Elderly & Morbidly Obese
– Fluid loading is poorly tolerated
– Vascular access may be difficult
– ECG changes
• Pregnant patients
– Blood supply increases significantly in a woman who is
at full term
– More information on that coming up toward the end
of this presentation
Disability
• Level of consciousness
– Best indicator of central perfusion & deterioration
of patient status
• Pupils
• Glucose Level
Disability Assessment
• Glasgow “best” response
– Eye opening
– Verbal response
– Motor response
• Total 3-15
• There is no such thing as a GCS of “zero”. Even a
rock has a GCS of at least 3.
GCS Pearls
• Acceptable noxious stimuli
– Armpit pinch or nailbed pressure
– Sternal rub, pinching web space between
fingers, pinching shoulder muscle
(trapezius)
– Earlobe pinch is out of favor
• Can cause movement of head & neck in
response to the pain
GCS Pearls
• The change in the GCS is more important than the
absolute score
• Check for associated injuries
– Manage a head injury as a multiple injured patient
until other injuries ruled out
• Stabilize the neck for any head injury
• Don’t assume the level of consciousness is altered
just because of ETOH and/or drugs
– Is there an occult (hidden) injury present?
• Provide accurate, clear, detailed documentation
Disability Assessment
• Possible causes of altered mental status:
AEIOUTIPS
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Airway
Endocrine
Insulin
Overdose
Uremia
Trauma/tumors
Infection
Psychosis
Shock/seizures
Disability Caveats
• Elderly:
– Hearing, visual, cognition, memory, perception,
communication, and motor deficits
– ≥ 65 with GCS ≤ 8 is poor prognosis
– ≥ 65 with RTS < 7 has 100% mortality
– Don’t control all restlessness with sedation
Disability Caveats
• Morbidly obese:
– Supine position = decrease range of motion
– Strength may be difficult to determine
– Look for asymmetry for injury
Environment/Exposure
• Flip them (back)
• Strip them (wounds, burns)
• Keep warm
• Caveats:
– Elderly: increase in hypothermia
– Morbidly obese: pull back skin
• Vital signs
– BP, HR, RR, Temp
• Manual BP
• Pulse pressure
– Narrowed = bleeding (<30 mmHg)
– Widened = increase ICP (>50 mmHg)
• Pulse
– Conscious palpate radial
– Unconscious palpate carotid
– Normal 60-100
– Bradycardia vs Tachycardia
– Rhythm
– Quality
– Location
• Current & Past Health History
• Sample:
– S: Symptoms
– A: Allergies
– M: Medications
– P: Past medical history
– L: Last oral intake, last LMP, last TD
– E: Events surrounding the incident
• MOI
– MVC
– Falls
– Struck by blunt object
– Penetrating wounds
– Violence/abuse
Caveats in Elderly
• Pain is often undertreated
• Polypharmacy – they take a lot of meds
already that affect their response to trauma
• Increased sensitivity to side effects
• Head to Toe Review
– Inspect
– Palpate
– Anticipate
– Percussion
– Auscultate
• Head to Toe Review
– HEENT
• Elderly:
– brain atrophies allows more blood to accumulate without
showing signs of ICP
– Neck
• Cervical fractures
– Chest/thorax/pulmonary system
• Head to Toe Review
– Abdomen (inspect, listen, palpate, percuss)
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Kehr’s sign
Seat belt sign
Cullen’s sign
Gray-Turner’s Sign
Contour
Old scars
Visible pulsations
• Head to Toe Review
• GU/Pelvis
– Palpate
• Gentle Inward/outward pressure
• No pelvic rock
• Head to Toe Review
– Extremities (6 P’s of pain)
– Back/Spine
• Log roll
– Skin & soft tissue
– Neurological
• LOC/GCS/Motor exam/Sensory exam
Standard Monitoring
• Cardiovascular
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Peripheral pulses
Skin color/temperature/moisture
BP
ECG
Heart sounds
Fluid volume (type and amount)
Drainage from wounds
Standard Monitoring
• Neurological
– Mental status (GCS)
– Content arousal
– Pupils
– Motor/sensory exam changes
– Seizure activity
Evaluation Pearls – Low SaO2
• SaO2 reading may be inaccurate in the presence of:
– Hemorrhagic shock with delayed capillary refill
– Hypothermia
– Lung damage
• Evaluate all parameters together to get the best overall
picture in ventilated patient
– Are you able to ventilate the patient?
– Are there extenuating circumstances where the
circulation is affected and would affect the pulse ox
reading like those listed above?
More
Case
Studies
Case Study #2
• Your 34 year-old patient
received a GSW to the
right upper abdomen.
• They are conscious and
alert; B/P 90/62; HR
120; RR 28; bleeding is
minimal
• What are your
interventions?
Case Study #2
• Make sure the scene is secured
• Consider need for spinal immobilization
• During assessment of wound, consider thoracic
injury in addition to abdominal injury depending on
the angle of the GSW.
• Examine for an exit wound
– Check the back and the axilla
• Prepare for the worst – assume the patient will
deteriorate before ED arrival
• Repeat VS: B/P 80/; HR 140; RR 32, remains
conscious and in pain
• Transport to a Trauma Center
Case Study #2 - Treatment
• Routine trauma care
• Question – is this an isolated abdominal wound or is it
a combination abdominal/ chest wound?
– Need to treat patient for potential injuries of both
body cavities
– EMS cannot determine in the field the angle of the
trajectory
• Cover the wound and watch for evisceration
• Fluid resuscitation – keep B/P normal; the higher the
B/P the faster the patient bleeds out
Case Study #2 - Documentation
• If patient states anything, put it in quotes
• If information available, add angle patient shot from (ie:
above, below) and distance from weapon
• If known, list type of weapon used
• Include results of inspection, auscultation, palpation
– Location of entrance and exit wound
– Size of wound(s)
– Assessment of the general area (ie: contusions, bleeding,
swelling/distention, pain, powder marks)
• Preserve evidence as much as possible
Case Study #3
• Your 10 year-old patient
has a penetrating injury
to the right leg above the
knee while playing in his
backyard
• Initial VS: B/P 90/70; HR;
130; RR 32; no active
bleeding
• Field interventions?
Case Study #3
• Next VS: B/P 92/64; HR 110; RR 20.
• Stabilize foreign body in place
• Obtain distal neurovascular status
– Distal pulses
– Movement – “can you wiggle your toes?”
– Sensation – “close your eyes and tell me which toe
I am touching”
• Document distal neurovascular status and
describe how the foreign object is stabilized in
place
Case Study #4
• Your 62 year-old
patient had
abdominal surgery 1
week ago. Today at
home he sneezed
hard and felt a
tearing sensation in
his abdomen and
called EMS.
• VS: B/P 100/60;
HR 110; RR 24
• No active
bleeding
• What
interventions
are appropriate?
Case Study #4 - Interventions
• Immediately cover the wound
– Need to minimize contamination
– Need to prevent more organs from protruding
– Need to prevent loss of fluids
• Place a saline moistened dressing over the exposed
tissue
• Place dry gauze over the saline dressings
• Can place light manual control over the organs to
prevent further evisceration especially during
movement, coughing, sneezing, deep breaths
Case Study #5
• 21 year-old drove into a metal fence. Upon EMS
arrival, there is obvious external chest injury with
bleeding. Coming closer to the patient, EMS can hear
a sucking sound from the chest wound.
• Patient is alert, in pain, severe dyspnea
• VS: B/P 90/62; HR 130; RR 34; GCS 15
• Breath sounds L > R
• Look at the injury – what is your impression and
what interventions are necessary?
MVC Into Metal Fencing
Case Study #5
• An adequate dressing will be difficult to
achieve with such an extensive wound
– A gloved hand just won’t be enough to get started
• This patient may be a candidate for conscious
sedation and intubation to provide positive
pressure ventilation
• Reassessment VS: B/P 80/56; HR 140; RR 36
GCS remains 15
• Transport
Case Study #5 - Treatment
• Open chest wounds need to be covered ASAP with a
non-occlusive dressing
• Carefully monitor if the treatment of the open chest
wound converts the injury into a tension
pneumothorax
• Carefully monitor the patient for the need for more
aggressive airway control (ie: supportive ventilation
via BVM or intubation)
– Initially can start O2 therapy with a non-rebreather
mask
Case Study #5 - Documentation
• What – cause of the injury (penetration, MVC,
pedestrian, etc)
• When – the injury occurred
• Where – by body location
– “quadrant” refers to the abdomen
– Chest injuries uses reference such as anterior/
posterior, nipple line, upper/lower chest wall
• How – the injury occurred
• Expand and give detail description of the
injury, treatment rendered, pt response
Case Study #6
• Your 45 year-old patient is a construction
worker who was accidentally shot in the head
with a nail gun
• Upon arrival, the patient is awake, alert,
talking (GCS 15)
• VS: B/P 132/78; HR 96; RR 20; complains of a
minor headache; minimal bleeding at a few
puncture wounds noted on the occipital area
of the scalp (patient has thick hair).
X-ray
from ED
No
deficits
noted
Case Study #6 - Treatment
• Consider any injury above the level of the clavicles to
include a c-spine injury until proven otherwise and
immobilize the patient
• Control bleeding
– The face and scalp have such a rich blood supply small wounds
tend to bleed heavily
• Protect from further contamination
– The open wound may be in direct contact with the brain
• Document neurological evaluation to establish baseline
for comparison (AVPU, GCS, movement)
Case Study #7
• You are called to the scene for a 10 year-old female
who has been run over by a bus
• As patient exited bus, she bent down to tie her shoe
and was caught under the wheels of the bus
• Upon your arrival, you note a large amount of
avulsed tissue with bleeding from the left hip, left
buttock, and left upper thigh area
• The patient is screaming in pain
• VS: B/P 110/70; HR 110; RR 26 GCS 15
• What is your impression?
10 y/o run over by bus
Case Study #7 –
• General impression
• Potential problems to consider & address
– Massive hemorrhage & control of hemorrhage
– Spinal injury
– Additional injuries
– Airway control
– Equipment to fit a 10 year-old
– Further wound contamination
Lastly
DOCUMENT
DOCUMENT
DOCUMENT
Caveats in Pregnancy
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General – treat the mom to treat the fetus
Airway
Breathing
Circulation
Disability
Anatomical and Physiological
Changes in the Pregnant Patient
• Cardiovascular
– Hemodynamic• Increased HR 10-20 bpm, increased SV, increased blood volume by
45-50%, increased cardiac output by 30-50%, SVR decreases
– Hematologic
• Increased WBC, decreased hemoglobin and hematocrit
– Hypercoagulation- excessive blood clotting
– Shock Considerations
• May not see S & S until >30% circulating blood volume is lost!!!
Anatomical and Physiological
Changes (con’t)
• Respiratory
– Increased MR, O2
consumption, decreased CO2
• Renal
– Bladder higher, kidneys
dilated, increased vascularity,
increased GFR
• Gastrointestinal
– Intestines higher, liver &
spleen enlarged, prolonged
gastric emptying
• Reproductive
– Blood flow through uterus
500-750ml/min, 1/6 total
maternal BV, 10-20% of CO,
hypoperfusion of uterus may
occur before signs of shock
• Musculoskeletal
– Changes in center of gravity
• Endocrine
– Enlarged thyroid
Strip O’ the Month
• PEA – Pulseless electrical activity
– Pulseless electrical activity is a clinical situation, not a
specific dysrhythmia
– Formerly called electromechanical dissociation (EMD)
• One of the more common “death rhythms” in
traumatic arrest.
– So common, “trauma” used to be included in the
possible causes (H’s and T’s)… but the most recent
ACLS algorhythm gets a little more specific than that
(hypovolemia, tension pneumo, etc).
Pulseless Electrical Activity
• PEA exists when organized electrical activity
(other than VT) is present on the cardiac
monitor, but the patient is pulseless
Causes: H’s and T’s
• The H’s include:
– Hypovolemia, Hypoxia, Hydrogen ion (acidosis),
Hyper-/hypokalemia, Hypothermia.
• The T’s include:
– Toxins, Tamponade(cardiac),Tension
pneumothorax, Thrombosis (coronary and
pulmonary).
PEA – Another Way to Remember
the Causes
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Pulmonary embolism
Acidosis
Tension pneumothorax
PATCH-4-MD
Cardiac tamponade
Hypovolemia (most common cause)
Hypoxia
Heat/cold (hypothermia/hyperthermia)
Hypokalemia/hyperkalemia (and other electrolytes)
Myocardial infarction
Drug overdose/accidents (cyclic antidepressants, calcium channel
blockers, beta-blockers, digoxin)
PEA – Intervention
• Begin CPR
• Search aggressively for possible cause(s) of the
situation
– Often finding the right “H” or “T” can solve PEA quickly
– Most common cause: hypovolemia
• Pharm: Epinephrine 1:10,000 IV/IO
• No More Atropine!!!
Questions?
Email afinkel@silvercross.org or call 815-300-7425 (or type into text box if watching
live).
Thank You for Your Attention
And a special thank you to Dr Wendy Marshall, Courtney McKibben RN MSN and
Sharon Hopkins RN MS for the use of some of their material