Physical Examination of the Injured Patient PHED 120 Krzyzanowicz – Fall ‘12

Objectives Identify and define the components of a physical examination for an injured patient in an emergency situation. Discuss appropriate scene assessment measures in order to establish safety relative to the provision of emergency care. Identify measures and supplies utilized to protect against the transmission of infectious diseases when providing emergency care. Identify and discuss the components of the primary survey using the ABCDE mnemonic. Identify and discuss the components of the secondary survey. Identify and discuss the six easily measured vital signs.

Physical Exam Procedures Four components: Inspection Examine the injured area looking for deformity, contusions, abrasions, swelling, bleeding Palpation Touch the injured area, feel for deformity/crepitus Percussion Not used often-used for thoracic and abdominal injuries Auscultation Listening to lungs and bowels with stethoscope

Scene Assessment Avoid tunnel vision Get a global picture of the scene How many patients are there? Hazards, such as electrical cords, water, blood? Is the patient moving?

Primary Survey Rapid head to toe assessment ID and immediately correct life and/or limb threatening injuries If yes, activate EAP ABCDE Stabilize cervical spine and check airway Check for breathing Check for circulation Check for neurological disability (or apply defibrulator) Check level of exposure

Airway and Cervical Spine Always assume an injured athlete has a neck injury Do not move this patient Check ABC’s Airway If no airway perform head-tilt-chin-lift or jaw-thrust (if on their back) Remove mouth guard if needed Listen for sounds

Breathing Look and feel for the chest to rise Patient is breathing in chest rises If no rise in chest, suspect patient isn’t breathing Will proceed to circulation Check nail beds for cynosis-a bluish color tint Normal breaths per minute for an adult is 12-24 (wide ranging)

Circulation Find pulse Radial pulse in wrist Is it strong? Weak? Irregular? Or absent? Check for 10 seconds, multiple number by 6 I.E., pulse of 12 for 10 seconds (12*6=72 bpm) Check capillary bed refill Press on nail bed of any finger Release quickly Note how quickly color returns

Disability/Defibrillation Disability refers to a brief neurological exam Will not do in this course AT students will do later on in program Defibrillation Will review this with CPR/AED sections later this semester

Exposure Clothing or equipment may need to be removed Hot and humid days Heat illness Cold weather Frostbite

Secondary Survey Complete head-to-toe examine to rule out other injuries that may not be apparent on the primary survey Look at Pupils PERRLA Pupils Equal Round Reactive Light Accommodation

Vital Signs Pulse Rate Blood Pressure Respiratory Rate Temperature Pulse Oximetry Pain

Pulse Rate Assessment sites Take for at least 30 seconds now Radial pulse (wrist) Brachial pulse (humerus) Inguinal pulse (groin) Dorsal pedal pulse (foot) Take for at least 30 seconds now Multiple number by 2

Pulse Rate Normal pulse rate Tachycardia Bradycardia Can vary 60 to 100 bpm Tachycardia Heart rate higher than 100 bpm Bradycardia Heart rate lower than 60 bpm Can vary Athlete in competition=high heart rate Runners-resting heart rate can be low, in the 40’s!

Blood Pressure How to take a blood pressure Patient is sitting Left arm exposed (shirt off, sleeve rolled, etc) Examiner is seated Place cuff around biceps Place stethoscope in cubital fossa (elbow) Pump cuff up to 200 mmHg Listen for first sound (top number) systolic Listen for second sound (bottom number) diastolic Release rest of air

Blood Pressure Normal Hypotension Hypertension 120/80 Usually 100/60 Over 120/80 Newer definition on hypertension Athletes should have a lower BP than normal population due to training Except football-lineman

Respiratory Rate Never tell the patient you are watching the breathe They will change their breathing pattern I try to do this while taking pulse I take pulse for 30 seconds; then next 30 seconds watch them breathe

Respiratory Rate Normal Tachypnea Bradypnea 12-24 breaths per minute Rapid rate Above 20 breaths per minute Asthma attack Bradypnea Slow rate Less than 10 breaths per minute Head injury, heart attack, etc

Body Temperature Normal 98.6 deg F Sites to take temperature Oral (most common and 2nd best) Tympanic (ear-not very reliable) Axillary (arm pit- not very reliable) Forehead (place hand on head-actually pretty good indicator, if you’re trained) Rectal Best and most accurate measurement Gold standard

Pulse Oximetry Usually pocket sized devices Shows how much oxygen is in your blood Oxygen saturation Should be close to 100 Never will be 100 Below 95 is a start of concern Below 90 is a huge concern

Pain Always ask about pain using a scale 0-10 Zero means no pain Ten means worst pain ever felt Actually a good indicator as well