Introduction to Emergency Medical Care 1 Advance Preparation Prepare multimedia graphics to illustrate various mechanisms of injury. Prepare assessment equipment for demonstration and psychomotor sessions. Invite programmed patients. Invite assistant instructors to assist with psychomotor sessions.

Topics Secondary Assessment of the Trauma Patient Detailed Physical Exam Comparing Assessments Planning Your Time: Plan 55 minutes for this chapter. Secondary Assessment of the Trauma Patient (20 minutes) Detailed Physical Exam (20 minutes) Comparing Assessments (15 minutes) Note: The total teaching time recommended is only a guideline.

Secondary Assessment “Head to Toe” of the Trauma Patient Teaching Time: 20 minutes Teaching Tips: Build on previous lessons. Link secondary assessment to scene size-up and primary assessment. Use a standardized skill sheet to give students a frame of reference from which to work. Initially, keep scenarios standardized. As students progress, add realistic twists. Use a programmed patient or anatomical model to demonstrate assessment technique. Describe realistic situations when discussing assessment decision making. Realism will improve critical thinking. Students will frequently attempt to verbalize elements of an assessment. Make students actually perform steps to promote muscle memory. Be sure to differentiate the rapid trauma assessment from the detailed assessment. Speed is essential in the rapid trauma assessment and students often become mired in detail. Use specific detail when discussing physical examination. Be careful of relying too much upon DCAP-BTLS. Make sure students have examples of what they are really looking for. Use video graphics to demonstrate mechanism of injury and discuss how these observations might impact assessment decision making.

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 trauma assessment Complete assessments in the correct sequence

Components of Secondary Assessment Focused history gathering Physical examination Points to Emphasize: The primary assessment evaluation and treatment must be completed before the secondary assessment. The secondary assessment of a trauma patient will be driven primarily by the mechanism of injury. EMTs generally assume spinal injury in the assessment of a trauma patient. Talking Points: Enough time must be spent at the scene to adequately assess the patient and give proper emergency care. If the mechanism of injury (MOI) is significant, you will do the focused history and physical exam differently than if the mechanism of injury is not significant.

Patient with No Significant MOI Assessment focused on areas patient notes are painful or that MOI indicates Chief complaint (why patient called EMS) History of present illness—information on how injury occurred Point to Emphasize: Although it is important to consider mechanism OF injury, a better way to look at this is to consider mechanism OR injury, because not just the mechanism of injury but also actual injuries to the patient must be assessed in forming a complete evaluation of the severity or potential severity of the patient’s condition. In a trauma patient with no significant mechanism of injury, the secondary exam will focus on areas identified in the chief complaint and by the mechanism of injury.

Elements of History of Present Illness Nature of force involved Direction and strength of force Protective equipment used by patient Actions taken to prevent or minimize injury Areas of pain and injuries resulting from incident Point to Emphasize: When getting the history of the present illness for a trauma patient, gather information on how the injury occurred in addition to relevant details. This information typically includes the nature of the force involved; the direction and strength of the force; equipment used to protect the patient; actions taken to prevent or minimize injury and areas of pain and injuries resulting from the incident. Discussion Topic: Describe the key elements of a history of the present illness with regard to a trauma patient. What are the important questions to consider? Knowledge Application: Practice taking patient histories. Hand out prewritten scripts to students and have their colleagues perform histories. Practice asking the appropriate questions.

Steps to a “Head to Toe” assessment Assess scene for safety Approach victim/PPE Get consent to treat (may have to be implied) As how injured/ what hurts Cervical Stabilization Mental Status (A-Alert, V-Verbal, P-pain only,U-unresponsive) Airway (Clear? Jaw thrust) Breathing (look, listen, feel) Circulation (bleeding?, Pulse, Cap refill, skin color and temp) Deformities (expose, and palpate) Vital signs (baseline) History

Physical Examination Areas assessed depend on injuries and chief complaint Mechanism of injury may point to potential injuries Three techniques: inspection, palpation, auscultation Point to Emphasize: In a focused exam, your decision on which areas of a patient’s body to assess will depend partly on what you can see and what the patient tells you (the chief complaint). Mechanism of injury must also be considered. Discussion Topic: Describe what criteria you would use to determine the area of focus during a focused assessment.

Physical Examination: Inspection Look for Abnormalities in symmetry Color Shape Movement Point to Emphasize: There are three techniques of physical examination that an EMT must master: inspection, palpation, and auscultation.

Physical Examination: Palpation Feel for Abnormalities in shape Temperature Texture Sensation

Physical Examination: Auscultation Listen for Decreased or absent breath sounds Discussion Topics: Describe the assessment of an unresponsive trauma patient. Define the three key elements of physical examination: auscultation, inspection, and palpation.

Physical Examination: DCAP-BTLS Deformities Contusions Abrasions Punctures and penetrations Burns Tenderness Lacerations Swelling Point to Emphasize: DCAP-BTLS is a memory aid that is used when performing the physical examination. It stands for deformities, contusions, abrasions, punctures and penetrations, burns, tenderness, lacerations, and swelling. Discussion Topic: Define the elements of DCAP-BTLS.

Deformities 15

Punctures/Penetrations Talking Points: Punctures and penetrations are holes in the body, frequently the result of gunshot wounds and stab wounds. When they are small, they are easy to overlook. That is why a detailed assessment is important, if time permits. 16

Swelling 17

Secondary Assessment— No Significant MOI Obtain baseline vital signs Obtain past medical history Knowledge Applications: Use multimedia graphics to illustrate various mechanisms of injury. Present scenarios and have the class discuss the type of secondary assessment that they would use in each case. Prepare the students for practical sessions with a written exercise. Have students write out and practice the steps of the secondary exam.

Baseline Vital Signs Signs—objective Symptoms—subjective Things you see, hear, feel, smell during exam Vital signs Sweaty skin, staggering, vomiting Symptoms—subjective Patient feels and tells you about Chest pain, dizziness, nausea Talking Points: A sign is objective—something you see, hear, feel, and smell when examining the patient. The vital signs are, of course, signs, as are sweaty skin, staggering, and vomiting, for example. A symptom is subjective—an indication you cannot observe but that the patient feels and tells you about. Such things as chest pain, dizziness, and nausea are considered symptoms.

Past Medical History SAMPLE Signs and symptoms Allergies Medications Pertinent past history Last oral intake Events leading to injury or illness Talking Points: The past medical history is often referred to in EMS as the SAMPLE history because the letters in SAMPLE stand for elements of the history: signs and symptoms, allergies, medications, pertinent past history, last oral intake, and events leading to the injury or illness. Discussion Topic: Define the elements of SAMPLE.

Apply Cervical Collar Apply if MOI, history, or signs and symptoms indicate use Make sure collar is correct size Measure three fingers width from the chin Point to Emphasize: Apply a cervical collar to any patient who may have an injury to the spine based on mechanism of injury, history, or signs and symptoms. Talking Points: The front height of the collar should fit between the point of the chin and the chest at the suprasternal (jugular) notch—the U-shaped dip where the clavicle and sternum meet. Once in place, the collar should rest on the clavicles and support the lower jaw. It should not stretch the neck (too high), it should not support the chin (too short), and it should not constrict the neck (too tight). continued

Apply Cervical Collar Assess patient’s neck prior to placing collar Reassure patient Size collar Remove jewelry and move hair continued

Apply Cervical Collar Slide collar into place from front continued

Apply Cervical Collar Collar alone does not provide adequate in-line immobilization Must be paired with manual stabilization or fixation to long board Discussion Topics: Describe the assessment of a trauma patient with no significant mechanism of injury. Describe the role of spinal immobilization during assessment of the trauma patient.

Secondary Assessment: Significant MOI Point to Emphasize: In a trauma patient with a significant mechanism of injury, a rapid trauma exam will provide a more expedited physical exam in anticipation of rapid transport. Talking Points: Assure manual stabilization of the patient’s head to prevent further cervical-spine injury. Manual stabilization must continue throughout the assessment until the patient is fully immobilized on a backboard. ALS may come in the form of intercepting paramedics or the nearest hospital. Continue manual stabilization Request Advanced Life Support services Complete head-to-toe rapid trauma assessment instead of focused exam

Video ABC assessment https://www.youtube.com/watch?v=vsvDUhqlfhs Cervical Collar application https://www.youtube.com/watch?v=cYxnp6ml8mE

Activity Create a “cheat sheet” that you can use while practicing assessments Include the steps of a head to toe assessment We will now be performing “Head to Toe” secondary assessments using a sample scenario. I will be observing you, make sure that you are following the correct assessment steps. You need to document your findings as you go. We will also demonstrate properly putting on a cervical collar. Exit ticket: Which step in the assessment is considered the most important?