Trauma: Patient Assessment

1
Trauma Patient Assessment Interventions

• Condell Medical Center EMS System
• Continuing Education
• April, 2004
• Site Code 107200E1204
• Prepared by Sharon Hopkins, RN, BSN, EMT-P

2
Objectives

• Upon successful completion of this program, the
  participant will be able to
• understand the steps in performing a trauma
  patient assessment
• discuss the trauma patient assessment process
• describe the indications for performing a needle
  decompression
• demonstrate needle decompression

3
Objectives continued

• describe the indications for performing
  cricothyrotomy
• demonstrate the cricothyrotomy procedure
• actively participate in discussion of field
  triage guidelines for accelerated transport
• actively participate in the discussion of atrial
  rhythms
• actively participate in case review studies
• successfully complete the quiz at 80

4
Performing a Trauma Patient Assessment

• What guides your decision in determining the flow
  of your trauma patient assessment?
• ?the mechanism of injury
• ?your index of suspicion
• ?your general impression

5
Mechanism of Injury -what is it?

• The processes and forces that cause trauma.

6
Index of Suspicion -what is this?

• The
  anticipation of injury to
• a body region,
  organ or
• structure based
  on analysis
• of the
  mechanism of injury.

7
General Impression - what is this?

• The Emergency Medical Technician - Basic or
  Paramedics immediate assessment of the
  environment and the patients chief complaint.
• What do you think is going on, what do you think
  is the problem, and what do you need to do about
  it (ie which protocol is appropriate to follow)?

8
How do you start to make a general impression in
this case?
9
Sometimes you wonder where to
even start!!!

• Always start at the beginning!

10
Steps in Trauma Patient Assessment

• Scene size-up
• scene safety
• crew, patient, bystanders
• BSIs
• mechanism of injury
• (or nature of illness for a
  medical call)
• number of patients
• need for additional resources

11
Whats your scene size-up for
this case?
12
Trauma assessment steps continued

• Initial Impression
• form a general impression
• what is the chief complaint?
• determine level of consciousness
• A - alert
• V - responsive to verbal stimuli
• P - responsive to painful stimuli
• U - unresponsive

13
Initial impression continued

• Assess airway control C-spine
• is the airway open and maintainable alone?
• is there a potential that the airway cannot be
  maintained on its own?
• are interventions necessary?
• modified jaw thrust
• adjunctive equipment
• oropharyngeal airways
• nasopharyngeal airways
• intubation

14
Initial impression continued

• Assess breathing
• what is the depth and rate of respirations?
• are interventions necessary?
• use of supplemental oxygen
• cannula or mask
• BVM
• what is the pulse oximetry reading?
• is cyanosis present?

15
Initial impression continued

• Assess circulation
• pulse rate, quality, regularity, palpable in
  which locations
• carotid pulse only usually indicates the systolic
  B/P to be around 60-80 mmHg
• quick head-to-toe visual sweep looking for
  obvious bleeding
• skin parameters - color
• -
  moisture
• -
  temperature
• capillary refill - more reliable in the pediatric
  population
• identify and treat any life-threats found

16
Initial impression continued

• Determine priorities
• indications for accelerated transport per SOPs
• unrelieved airway obstruction
• inadequate breathing evidenced by the presence
  of
• sucking chest wound
• large flail
• tension pneumothorax
• major blunt chest injury
• traumatic arrest
• shock
• uncontrolled hemorrhage
• head injury with decreasing level of consciousness

17
Focused History Physical Exam

• Significant mechanism of injury
• rapid trauma assessment looking for other life
  threats
• inspect, palpate, auscultate
• DCAP-BLS-TIC head-to-toe
• D - deformities T-tenderness
• C - contusions I- instability
• A - abrasions C-crepitation
• P - penetrations
• B - burns
• L - lacerations
• S - swelling

• No significant mechanism of injury
• focused assessment evaluating for specific injury
• (ie cut finger, sprained or
• fractured ankle)
• DCAP-BLS-TIC to assess the area
• PMS - evaluation of distal pulse, sensory, and
  movement

18
Physical exam continued

• Baseline vital signs - all components together
  are helpful in the assessment process
• pulse rate and quality
• respiratory rate and effort
• blood pressure
• skin parameters
• pupillary response
• pulse oximetry
• pain scale of 0 -10

19
Physical exam continued

• SAMPLE History
• S - symptoms
• A - allergies including iodine
• M - current meds including natural herbal
• medicines
• P - past pertinent medical history
• L - last oral intake (anything to eat or drink)
• E - events preceding incident

20
Detailed Physical Exam

• a luxury when there is a significant mechanism of
  trauma
• performed enroute only if there is time
• if patient is that critical a detailed exam after
  a rapid trauma assessment has been completed is
  usually not done - youre too busy doing other
  priorities
• when performed, is more detailed and slower than
  a rapid trauma assessment

21
Ongoing Assessment

• Performed to
• ? detect trends
• ? determine changes in the patients condition
• ? assess effectiveness of your interventions
• Stable patients - perform every 15 minutes
• Unstable patients - perform every 5 minutes
• DOCUMENT DOCUMENT
  DOCUMENT

22
Components of the Ongoing Assessment

• mental status
• ABCs
• vital signs
• focused assessment based on chief complaint -
  include any new complaints
• reassessment of any and all interventions started
  in the field

23
Reevaluation Questions

• Are your interventions working,
• effective, doing the job?
• Do you need to revise your action plan?
• Are you flexible enough to switch treatment
  options if your first choice is not working?

24
Interventions for life threatening conditions of
airway obstruction

• mechanical means to relieve obstructions and
  provide ventilations have been tried and failed
  (bagging pt, magill
• forceps, heimlich, intubation)
• time is essential
• EMS must be prepared to
• perform an emergency
• cricothyrotomy

25
Melker Emergency Cricothyrotomy

• Indications
• to access an airway in an emergency situation,
  when endotracheal intubation cannot be utilized
• temporary emergency procedure

26
Cricothyrotomy continued

• Contraindications
• inability to identify the cricothyroid membrane
• under the age of 8 unless landmarks of the
  cricothyroid membrane are clearly definable
• burns or infection over the incision site
• direct trauma obscuring landmarks

27
Melker Catheter Equipment

• radiopaque polyvinyl chloride airway catheter
• tapered curved dilator with a handle design to
  fit within the airway catheter
• extra-stiff wire guide with single flexible end

• 15 scalpel
• 6 cc syringe
• 18 gauge introducer needle
• 18 gauge teflon catheter introducer needle

28
Finding Landmarks - Cricothyroid Membrane

• palpate the Adams apple (laryngeal prominence)
  or thyroid cartilage on the anterior surface of
  the neck
• below (inferior to) the thyroid cartilage is
  palpated the cricoid cartilage (firm bump
  palpated before the last depression above the
  sternal notch)
• cricothyroid membrane connects inferior border of
  thyroid cartilage with superior aspect of cricoid
  cartilage

29
Cricothyroid Membrane Landmarks
30
Insertion Steps

• locate palpate cricothyroid membrane
• prep the site with aseptic solution
• (ie alcohol wipe)
• stabilize the thyroid cartilage with your fingers
• make a vertical (up and down) incision through
  the skin with the scalpel long enough to insert
  airway device (1/2 (1 cm) adequate for most max
  up to 1 (2cm) may be needed)

31
Insertion steps continued

• with a 6cc syringe attached to the 18G
  introducer catheter or needle, advance the needle
  at 450 angle aiming towards the feet (caudad)
• advance catheter while aspirating for free air to
  confirm placement in the airway
• remove syringe and needle and leave catheter in
  place

32
Insertion steps continued

• advance the wire guide through the catheter, soft
  flexible end first, only a few inches (some wire
  guide remains hanging out)
• remove the catheter by pulling over the wire
  guide, leaving wire guide in place
• advance the dilator catheter assembly, tapered
  end first, over the wire guide until completely
  in the trachea and wire guide protrudes from
  proximal end of catheter

33
Insertion steps continued

• lubrication may be used on the surface of the
  dilator
• always be able to visualize the proximal end of
  the wire guide
• remove wire guide and dilator simultaneously
• ventilations need to be provided immediately with
  the ambu bag

34
Insertion steps continued

• connect the BVM to the standard 15-22 mm adaptor
  on the airway catheter and begin to ventilate the
  patient
• assess for bilateral breath sounds
• secure the airway catheter with cloth ties
  provided

35
Technical Tips of Melker Device

• Always visualize the proximal end of the wire
  guide during airway insertion (need to prevent
  inadvertent loss of wire into trachea)
• Do not insert the tip of the dilator beyond the
  tip of the wire guide in the trachea
• The proximal end of the airway catheter is sized
  with a standard 15/22mm adaptor to fit the BVM as
  you assess for bilateral breath sounds

36
Life-threatening Conditions Affecting Breathing

• Conditions that can result in inadequate
  breathing
• sucking chest wound
• large flail chest
• tension pneumothorax
• major blunt chest trauma

37
Sucking Chest Wound

• open wound to the chest with air passage into
  pleural space
• immediately seal an open wound (minimally with a
  gloved hand then replace with a dressing)
• tape the dressing on 3 sides to create a one-way
  relief valve
• watch for conversion from open chest wound to a
  tension pneumothorax
• be prepared to burp the dressing

38
Large Flail Chest

• 3 or more adjacent ribs broken in 2 or more
  places
• reduces tidal volume (air moving in or out)
• increases respiratory effort
• usually accompanied with pulmonary and possibly
  cardiac contusions
• treat patient with support of respirations and
  supplemental oxygenation

39
Flail chest
40
Flail Chest
41
Tension Pneumothorax

• an open or simple pneumothorax that generates and
  then maintains a pressure greater than
  atmospheric pressure within the thorax
• a one-way valve forms
• air is trapped in the pleural space and tension
  builds

42
Tension pneumothorax putting the squeeze on the
lungs
43
Tension pneumothorax
44
Signs and Symptoms of Tension Pneumothorax

• dyspnea/SOB
• tachycardia
• hypotension
• cyanosis
• diaphoresis
• altered mental status
• tracheal shift away
• JVD (jugular venous distension)

• narrowed pulse pressure (distance between
  systolic diastolic B/P numbers moving closer
  together
• diminished then absent breath sounds
• low pulse oximetry reading
• may or may not have experienced chest trauma

45
Treatment of Tension Pneumothorax - Needle
Decompression

• BSIs
• prepare equipment
• alcohol pad to wipe the skin
• 12 or 14 G 3 needle catheter
• flutter valve (finger cut from a glove threaded
  onto needle)
• identify landmarks
• 2nd or 3rd intercostal space midclavicular line
• top of rib space (trying to avoid puncture of
  nerves or vessels that run under the rib)

46
Needle Decompression landmarks
47
Steps for Needle Decompression

• cleanse site
• insert needle with flutter valve attached over
  the top of the rib
• feel for pop when entering pleural space
• advance catheter as you remove stylet
• secure flutter valve catheter (tape gauze)
• reassess patient
• document what, where, patient response

48
Regarding Accelerated Transport Patients

• Remember that these patients will require
• rapid transport
• supplemental oxygenation
• application of the EKG monitor
• IV access enroute to the hospital
• frequent reassessment
• report to receiving facility (usually
  abbreviated)

49
Review of Atrial Rhythms

• 
  ?What is the criteria for
• 
  atrial rhythms?
• ? Can I
  identify the
• 
  characteristics on a strip?
• ? Do I know what to do for
• symptomatic patients?

50
Rhythm Interpretation Practice

• Steps in rhythm identification
• is the rhythm regular or irregular?
• whats the heart rate
• are there P waves and are they consistent?
• what is the PR interval (normal
• are the QRS complexes following a P wave?
• what is the QRS complex (normally
• whats your interpretation?
• whats the implication to the patient?

51
Atrial Rhythms Defined

• atrial dysrhythmias reflect abnormal electrical
  impulse formation and conduction in the atria
• atrial dysrhythmias result from altered
  automaticity, stimulated or triggered activity,
  or reentry (problems with impulse formation and
  with impulse conduction)

52
Atrial Dysrhythmias due to Altered Automaticity

• atrial cells can depolarize and initiate impulses
  before a normal sinus impulse
• conditions that may cause altered automaticity
  can include myocardial ischemia, drug toxicity,
  hypocalcemia, electrolyte imbalance
• examples include
• PACs, SVT, atrial flutter atrial fibrillation

53
Atrial Dysrhythmias due to Stimulated or
Triggered Activity

• abnormal electrical impulses sometimes occur
  during repolarization when cells are normally
  quiet
• causes include hypoxia, ? in catecholamines,
  hypomagnesia, myocardial ischemia and injury, and
  certain medications
• examples include atrial beats that occur
  singly, in pairs, or runs

54
Atrial Dysrhythmias due to Reentry

• an impulse returns to stimulate tissue that was
  previously depolarized
• dependent on 3 conduction defects ?conduction
  circuit or pathway availability, ?block within
  part of the circuit, and ?delayed conduction
  within remaining part of the circuit
• causes include hyperkalemia, myocardial
  ischemia, some antidysrhythmic medications
• Examples include PACs and PSVT

55
Supraventricular Tachycardia

• Describes all tachydysrhythmias that originate
  above the bifurcation of the bundle of His
• Includes
• sinus tachycardia atrial tachycardia
• atrial fibrillation atrial
  flutter
• junctional tachycardia
• Dysrhythmias have rapid ventricular response,
  narrow QRS complex, and usually an uncertain
  origin (atrial or junctional)

56
Atrial Tachycardia (type of SVT)

• a rapid, repetitive complex originating in the
  atrium
• the rhythm is regular
• rate usually 150 - 250 beats per minute
• P waves are present but differ from sinus P wave
  P waves are usually peaked
• if onset termination abrupt, called paroxysmal
  atrial tachycardia (PAT)
• if P waves are not visible then rhythm called
  supraventricular tachycardia (SVT)

57
Atrial Flutter

• irritable focus is within the atria that
  typically depolarizes at a rate of 300/min
• waveforms are produced that resemble teeth of a
  saw (saw-toothed) or a picket fence appearance
• chronic atrial flutter rare (rhythm usually
  converts to sinus rhythm or atrial fibrillation)
• healthy AV node protects ventricles from too fast
  of an atrial rate bombarding the ventricles

58
Atrial Fibrillation

• multiple reentry circuits in the atria
• this rhythm may occur acutely, intermittently, or
  be chronic
• muscles of the atria quiver so there is no atrial
  contraction with loss of atrial kick and
  therefore a decrease in cardiac output
• AV node is a safety check in slowing down or
  blocking some impulses originating in the atria
  from traveling to the ventricles

59
Points to ponder on atrial rhythms

• The patient is compromised when the ventricular
  response is too fast and ventricular filling time
  is decreased.
• The heart cannot function as an effective pump
  when the atrial rates are too fast (there is a
  20 atrial loss to ventricular filling when the
  atria do not squeeze their blood volume down to
  the ventricles with a resultant decrease in
  cardiac output totals for distribution to the
  general circulation)

60
General Treatment Approach to Rapid Atrial Rhythms

• Treatment depends on the severity of signs and
  symptoms (is patient stable or unstable?)
• Relatively stable patients (this means that some
  signs symptoms may be present in the setting of
  high rates but the patient is tolerating them)
  are treated usually pharmacologically (ie vagal
  maneuvers, adenosine 6mg rapid IVP with rapid IVP
  NS bolus)
• Unstable patients are treated with electrical
  synchronized cardioverison

61
Whats this rhythm?

• Sinus Tachycardia

62
Whats this rhythm?

• Sinus Rhythm with a wide QRS

63
Whats this rhythm?

• Atrial fibrillation

64
Whats this rhythm?

• Atrial Flutter - variable degree of block

65
Whats this rhythm?

• Supraventricular tachycardia

66
Whats this rhythm?

• ? Atrial Tachycardia
• (P waves differ from sinus P waves - more peaked,
  shortened PR interval)

67
Whats this rhythm?

• Atrial Fibrillation

68
Whats this rhythm?

• Atrial fibrillation

69
Whats this rhythm?

• Atrial Flutter with 21 conduction

70
Case Study 1 - 32 year old male driver struck a
deer

• Heres the mechanism of injury
• Whats your index of suspicion?
• Whats your general impression?

71
Case Study 1 Findings

• The patient presents with obvious difficulty
  breathing, cyanosis, chest contusions on the
  right, increased respiratory rate, decreased
  breath sounds on the right, tachycardic pulse
• Are there any major life-threats identified?

• Tension pneumothorax

72
Case Study 1 - Interventions

• consider oxygenation support
• consider support of ventilations (does the
  patient need to be bagged?)
• perform emergent needle decompression
• prepare equipment
• identify landmarks
• perform the procedure
• evaluate intervention - did it work?
• document activity

73
Case Study 2 - Findings

• 28 year old male who received a crush injury to
  his neck
• the patient cannot be be ventilated due to
  injuries

74
Case Study 2 - Assessment

• mechanism of injury - crush injury to neck
• index of suspicion - airway totally blocked
  unable to be ventilated with mechanical means
• general impression - full airway obstruction that
  needs to be treated with emergency cricothyrotomy

75
Case Study 2 - Interventions

• prepare equipment
• identify landmarks
• perform procedure
• reevaluate success of the intervention

76
Bibliography

• Aehelrt, B. ECGs Made Easy 2nd Edition. Mosby.
  2002
• Bledsoe, BE, Porter, RS, Cherry, RA. Paramedic
  Care Principle Practice. Brady 2001.
• Campbell, JE. Basic Trauma Life Support 4th
  Edition. Brady, 2000.
• Limmer, D, OKeefe, MF, Grant, HD, Murray, Jr,
  RH, Bergeron, JD. Emergency Care 10th Edition.
  Brady. 2001.
• Melker Emergency Cricothyrotomy Catheter Sets
  video. Cook Interventional Critical Care
  Products. 2003.
• Sanders, MJ. Paramedic Textbook. Mosby. 2001.
• www.randylarson.com/acls/start.html
• www.nurse-anesthesia.com