Rapid Trauma Assessment

State Standard 20) Accurately perform the components of patient assessment to identify and manage immediate life threatening illnesses and injuries within the scope of practice of the EMR for pediatric, adult, and geriatric patients, utilizing rubrics from textbooks, National HOSA guidelines, or clinical standards of practice. Include the following areas: a. Scene Size-up b. Primary Survey or Assessment c. History Taking d. Secondary Assessment e. Reassessment

Objectives Students will be able to… Identify components of a rapid trauma assessment Demonstrate a rapid trauma assessment

Rapid Trauma Assessment Requires only a few moments Should be performed at scene Care provided en route will be based on this assessment Point to Emphasize: Although the mechanism of injury can provide a lot of information about the kinds of injuries a patient may have, there is still the possibility that patients will have “hidden injuries.”

Components of Rapid Trauma Assessment Head Neck Chest Abdomen Pelvis Back Extremities Baseline vital signs Knowledge Application: Use manikins to practice rapid trauma assessments. Coach this session well and have a keen eye for time. Do not let students turn rapid trauma assessments into detailed assessments.

General Principles In all areas look for DCAP-BTLS or other abnormal findings Communicate with patient Expose injured area before examining it Assume spinal injury Stop or alter assessment process to provide care Talking Points: Respect cultural modesties and differences as you lay hands on a patient. Be sensitive to their feelings and misgivings. Communicate. Class Activity: Use SAMPLE or DCAP-BTLS as a take home assignment. Have students perform assessments and report back their findings using the above listed acronyms. Knowledge Application: Use programmed patients and moulage. Have students practice both assessment decisions and the actual assessments.

Head and Neck In addition to DCAP-BTLS, look for Cerebrospinal fluid in ears and nose Unequal pupils Jugular venous distention Consider applying cervical collar Talking Points: Jugular vein distention is present when you can see the patient’s neck veins bulging. The neck veins are usually not visible when the patient is sitting up. If they are bulging when the patient is upright, it means that blood is backing up in the veins because the heart is not pumping effectively. This could be the result of a tension pneumothorax or cardiac tamponade. However, it is normal to see bulging of the neck veins when the patient is lying in a horizontal position or with head down.

Chest and Abdomen In addition to DCAP-BTLS, look for Paradoxical motion Crepitation Equal breath sounds Distention Talking Points:

Chest and Abdominal Findings Distention is another way of saying the abdomen appears larger than normal. One of its causes can be internal bleeding. Crepitation is the sound or feel of broken bones rubbing against each other Paradoxical motion- movement of part of the chest in the opposite direction from the rest of the chest is a sign of a serious injury. several ribs have broken at two ends and are “floating” free of the rest of the rib cage..

Distension

Paradoxical Movement

Assessing the Chest Talking Points: Hands placed on the chest can identify paradoxical movement and crepitation.

Assessing the Abdomen Palpate all four quadrants Talking Points: Palpate the abdomen in each of the four quadrants. Palpate all four quadrants

Pelvis and Extremities In addition to DCAP-BTLS, look for Distal circulation, sensation, and motor function Talking Points: A priapism is a persistent erection of the penis that can result from spinal cord injury or certain medical problems.

Assess Distal Circulation, Sensation, Motor Function Critical Thinking: You are treating a trauma patient approximately three blocks away from the hospital, and you find yourself needing to maintain his airway. How will you complete the secondary assessment of this patient?

Posterior/Back Roll patient to assess back Discussion Topic: Describe the assessment of a trauma patient with a significant mechanism of injury. Class Activity: Assign each student a trauma scenario. Ask the student to determine which type of secondary assessment would be most appropriate under the circumstances. Have students write out the steps of their assessment. Have them work on the assessment at home and report on their conclusions in class. Knowledge Application: Describe significant trauma situations and discuss the role of ALS. Consider local challenges and protocols for obtaining advanced care. Roll patient to assess back

Think About It What criteria would you use to decide whether to perform a focused exam or a rapid trauma exam? Talking Points: A focused exam is used for patients with no significant mechanism of injury. A rapid trauma exam is used for severely injured patients, patients who are unable to communicate with providers, or patients with a significant mechanism of injury.

Trauma Assessment: Pediatric Note Lesser mechanisms can cause significant damage Need to explain assessments more thoroughly in this population Knowledge Application: Use pediatric manikins or actual children to practice assessment. Discuss how the approach differs from that of an adult.

Detailed Physical Exam Teaching Time: 20 minutes Teaching Tips: Use a standardized skill sheet to give students a frame of reference from which to work. Use a programmed patient or anatomical model to demonstrate assessment technique. Use real-world examples and “war stories” to point out the importance of finding subtle injuries. Emphasize a “hands on” approach. This lesson is easy to verbalize; however, a good detailed assessment requires actual contact with the patient.

Detailed Physical Exam Typically completed en route to hospital Gathers additional information Complements primary and secondary assessments Performed after all critical interventions completed Primary assessment re-evaluated again before initiating Points to Emphasize: Performing a detailed physical exam is always a lower priority than addressing life-threatening problems. The purpose of the detailed physical exam is to gather additional information about the patient’s injuries that was not found in the primary or secondary assessments. Talking Points: It is reasonable to defer the detailed exam for critical intervention. Frequently this will mean that a detailed exam does not get initiated before arrival at the ED. This is acceptable. However, when possible the detailed assessment should be completed as it may identify problems not found in the less detailed rapid trauma exam. Discussion Topics: Describe the components of a detailed assessment. Considering the overall patient assessment, discuss when a detailed assessment would be utilized. Knowledge Application: Have students work in groups. Assign each group a trauma scenario and a specific type of patient. Have the groups discuss how and when they would conduct their detailed assessments.

Performing Detailed Physical Exam Expose patient Work around immobilization equipment Components similar to rapid trauma exam More detail and focus Points to Emphasize: The detailed assessment is similar to the rapid trauma assessment but is conducted with a higher level of scrutiny. The more severe the mechanism of injury, the higher the requirement to search for subtle injuries (if time and patient status allow). Discussion Topic: Compare and contrast the detailed assessment and the rapid trauma assessment. How are they similar? How are they different? Class Activity: Have students write out a detailed assessment. Assign homework to list the components of a detailed assessment. Ask students to attempt to list from memory first and then to correct, using resources. Knowledge Applications: Assign detailed assessments as homework. Have students complete standardized skill sheets at home. Assign five detailed assessments to be completed prior to the next session. Have students work in groups. Assign each group a region of the body; then have the groups discuss the potential traumatic findings associated with a detailed assessment. Critical Thinking: What findings might you look for in the detailed assessment of a trauma patient?

Think About It Is it necessary to always complete a detailed assessment on a trauma patient with no significant mechanism or injury? Talking Points: This is a difficult question. Although it may not be absolutely necessary, you must assure that all the elements of a detailed assessment can be addressed. This may mean communicating with the conscious patient or it may mean actually completing a detailed assessment. Each situation must be judged individually and this decision depends greatly upon your confidence level and the patient’s ability to communicate problems.

Responsive Child: No Significant MOI Chief complaint Physical exam Baseline vital signs History Detailed physical exam and further care Points to Emphasize: The assessment of trauma patients will vary, depending on the status of the patient and the mechanism of injury. Use a focused assessment and a detailed assessment that is directed by the mechanism of injury on a trauma patient who has no significant mechanism of injury. Discussion Topic: Describe the assessment of a trauma patient with no significant mechanism of injury. Class Activity: Using standardized skill sheets and a programmed patient in a trauma scenario of your choice, demonstrate the appropriate steps of an assessment.

Unresponsive Adult: Significant MOI History of present illness Manual stabilization of head and neck ALS request Rapid trauma assessment Baseline vital signs Past medical history Detailed physical exam Point to Emphasize: Use a rapid trauma assessment and a thorough detailed assessment (if time permits) on a significant mechanism of injury. Discussion Topics: Describe the assessment of a trauma patient with a significant mechanism of injury. Describe the assessment of an unresponsive trauma patient. Knowledge Application: Have students work in groups. Assign each group a trauma scenario. Discuss each strategy for assessment. Critical Thinking: A 21-year-old male has been found unconscious. There is no apparent mechanism of injury. How might you assess this patient?

Rapid Physical Assessment Video https://www.youtube.com/watch?v=P3MUhF48zi8 6 minutes

Activity We will now be practicing performing a rapid head to toe assessment on a mannequin using a scenario. Exit ticket: Individually list the steps of the rapid trauma assessment and describe the types of patient injuries the rapid trauma assessment is used for.