Patient Assessment - Trauma with Signifcant Injury

Scene Size-Up
-Body Substance Isolation
-Scene Safety
-Determine the Mechanism of Injury/Nature of Illness
-Determine number of patients
-Request additional resources
-Consider C-spine immobilization

The first part of patient assessment is the scene size-up. When you arrive on scene you'll perform Body Substance Isolation(BSI) equipment, which could range from latex gloves to a full body contamination suit, depending on your training and the situation at hand. You will attempt to see if you can recognize the mechanism of injury, or the nature of the illness(MOI/NOI). You will need to determine the number of patients you have, which will be vital if it is a triage situation, and to alert medical control of how many patients you'll be bringing in. During the scene size-up you will consider what additional resources you may need, such as Advance Life Support(ALS), fire department, police, power company, etc. Finally you will consider if the patient needs c-spine immobilization.

Initial Assessment
-General Impression
-Assess Mental Status
-Assess Airway
-Assess Breathing
-Assess Circulation
-Prioritize Patient

The part of the initial assess will be to get a general impression of your patient. You will then ascertain the patient's mental status using the AVPU scale. If the patient can answer your questions, such as where they are, who they are, what year it is, the patient is considered to be alert. If the patient cannot answer your questions, or is disoriented, but can respond to your voice the patient is said to be verbally responsive. If the patient cannot respond to your voice, but responds to painful stimuli, such a rubbing the sternum or pitching the earlobe, the patient is said to be pain responsive. If the patient does not respond to any outside stimuli they are considered unresponsive.
The next step is to assess the ABC's, which stand for airway, breathing, and circulation. In an unconsciouspatient, you must open the airway for them. If there is no sign of c-spine damage, use a head tilt chin lift to open the airway. If there is suspect damage to the c-spine, use a modified jaw thrust to open the airway. Next you would put your cheek next to their mouth and nose to look, listen, and feel for breathing. If there is no breathing, then begin CPR. If the airway is open, and the patient is breathing, then insert an oropharyngeal airway, or a nasopharyngeal airway if there is trauma to the mouth. Then assess the person circulation at the carotid and radial pulse points. You will then check the body voids for gross bleeding by performing what is sometimes known as a clam maneuver. You will place your gloved hands under the patient’s head, and then remove them, looking to see if there is any bleeding. Continue down the patient’s body, and then check the extremities the same way. if any gross bleeding is found, you should stop your assessment, and stop the bleeding first. The final step of the initial assessment is to prioritize your patient.

Medical/Trauma Patient
After you have completed your initial assessment your patient will classified as either medical, meaning affecting the homeostasis of the body, or trauma, meaning outside forces have injured the body. It is always important to remember that patients may suffer from multiple problems, such as an elderly patient who has suffered a heart attack and fell, may also have a fractured pelvis. Once you have classified your patient as medical or trauma, you must classify their condition. Trauma patients have either a significant mechanism of injury, or there is no significant mechanism of injury. Medical patients are classified as either responsive, or unresponsive.

Trauma Patient - Significant Mechanism of Injury
-Rapid Trauma Assessment
-Baseline Vitals and SAMPLE History
-Perform Interventions
-Transport

Dealing with a trauma patient with a significant MOI, you first do a rapid trauma assessment. you will quickly palpate all major areas of the patient’s body, always looking for DCAP-BTLS. Rapid trauma assessment can be broken down into nine steps.
1)Continue spine immobilization, and be aware of any change the patients ABC's, or their mental status.
2)Palpate the head, looking and feeling for DCAP-BTLS, and crepitus.
3)Assess the neck, looking and feeling for DCAP-BTLS, crepitus, jugular vein distention, and tracheal deviation.
4)Size and apply a cervical collar.
5)Palpate the chest, looking and feeling for DCAP-BTLS, crepitus, paradoxical motion(unequal rise and fall on either side of the chest), and auscultate(listen) to breath sounds at the mid-clavicular(found midway between the shoulder and neck, immediately below the collar bone), and mix-axillary(found in middle side of the chest, between the armpit and the bottom of the rib cage) regions of the chest.
6)Palpate the abdomen, looking for DCAP-BTLS, guarding, rigidity, distention, or rebound tenderness(painful response). The abdomen can be split into four different quadrants; right upper quadrant, left upper quadrant, right lower quadrant, and left lower quadrant. This always refers to the patient's left, or right. Palpate by gently placing your hands flat, one on top of the other, and gently but firmly pushing down on the four quadrants. Note findings.
7)Palpate and look for DCAP-BTLS on the pelvis. If there is not pain response, gently grab either side of the pelvis and push in and down to determine if there is any instability, paradoxical movement, or crepitus. Check the genital area for blood, or discharge of any kind. Look for a condition known as priapism in males, which is a painful sustained erection indicative of spinal injury, or certain types of diseases.
8)Palpate the extremities looking for DCAP-BTLS. Palpate down one leg, then the other, checking pulse points regularly. Then, palpate the legs at the same time, looking for any differences. Check the arms in the same manner.
9)Taking spinal precautions, roll the patient onto their side, and palpate the back looking for DCAP-BTLS. The patient should then be rolled onto a long spine board.

Next you would take baseline vital, including pulse rate, blood pressure, and respiration rate.

You will then take a SAMPLE history. Ask the patient if they can answer you questions, ask family witnesses to the trauma, and check for medical alert bracelets.

At this point you will perform interventions that cannot wait until the patient is loaded on the ambulance for transport i.e. applying a traction splint for a fractured femur.

Now you would perform a detailed physical exam. A detailed physical exam is always necessary on a patient who experienced a traumatic incident. A detailed physical exam is the same as the rapid trauma assessment, with the main difference that more time is spent on the head, and face, area. Checking the ears and nose for blood, and a cerebral spinal fluid(CSF), indicating cranial damage. Check behind the ears for contusions called "battle signs", which also indicate cranial damage. Palpate the facial bones for crepitus, and DCAP-BTLS. Check the eyes with a penlight, using the mnemonic PEARRL(Pupils Equal And Round Regular Light reactive). Also check the extremities for sensory motor function. If the patient is conscious check the closest pulse point, the ask the patient if they can feel your touch, then ask them to grab or push against your hands so you can ascertain some idea of their strength in the extremities. If the patient is unconscious, check pulse, and run something flat along the bottom of the foot, or palm, checking for a reflex response.

Ongoing Assessment
-Repeat Initial Assessment
-Repeat Vital Signs
-Repeat Focused Exam
-Recheck Interventions

First you will repeat your initial assessment of the patient, always paying close attention to the patient’s airway, breathing, and circulation status.

Recheck the patient's vital signs(pulse rate, respiratory rate, and blood pressure). Vital signs need to be taken, at the most, every five minutes for a unstable patient, and every fifteen minutes for a stable patient.

Repeat a focused exam by performing a detailed physical exam again.

Recheck any interventions you may have applied i.e.flow rate of your oxygen.

Final Note

This is general outline of how to deal with a patient suffering from a significant traumatic injury. Local protocol in certain places may have you check the pupils as part of your baseline vitals instead of during the detailed physical exam. Other areas, such as Alaska, may require you to build a tent around an accident site, and give all patients warm humidified oxygen. Still, wherever you go, you will find some version of the above algorithm for dealing with patients.