Post Professional-DPT Course: Emergency Procedure and Patient Care-Lec-2

Physical Examination of the Critically Injured person physical examination Scene assessment and safety Body substance isolation precautions Primary survey Secondary survey Vital signs

Physical Examination  Four components: 1.Inspection 2.Palpation 3.Percussion 4.Auscultation

Inspection  Inspection involves a close examination of the injured area looking for; a)Deformity b)Contusions c) Abrasions d) Swelling e)Bleeding.

Palpation  Palpation involves touching the injured area to note abnormal findings such as; a)Deformity b)Crepitus.

Percussion  Percussion consists of tapping the injured area to elicit tympanic sounds.  Percussion is used for thoracic and abdominal injuries

Auscultation  Auscultation refers to listening to lung sounds with a stethoscope and, although difficult in a noisy environment.

Scene assessment and safety  Tunnel vision should be avoided; When approaching a person who is down, get a global picture of the scene.  Make sure the scene is safe for you to be there.  How many persons are injured?  Are there hazards in the area such as electrical cords, water, or blood?  Do you have sufficient resources and equipment to manage the injured person?  If the person is an assault victim,  where are the assailant and the weapon?  Failure to see the big picture is often called tunnel vision and can lead to significant dangers being missed

Body Substance Isolation Precautions  Protection against the transmission of infectious diseases such as Hepatitis B or HIV.  The degree of protection depends on the procedure performed and the body fluids you might come in contact with.  Hand washing is the single most effective way to prevent the transmission of diseases.  Use warm water if possible.  Rinse completely with a strong stream of water and dry completely.  Waterless alcohol based soap can be used in absence of soap and water.  Repeated use of these waterless soaps is not recommended.

Human Immunodeficiency Virus (HIV)  The human immunodeficiency virus (HIV) attacks the cells of our immune system, causing AIDS.  Ways of transmission:  Through blood  Sexual contact  From a pregnant mother to her unborn child.  Although there is not yet a cure for AIDS but the disease could be controlled through precaution.

Hepatitis B Hepatitis B is 100-times more transmissible than HIV or hepatitis C because of the high volume of hepatitis B viruses in the blood of infected people, compared to the lower viral load in people infected with HIV or hepatitis C. A safe and effective vaccine does exist that prevents HBV infection, but unfortunately, not all patients have been immunized. ( )

Level of Protection for Various Procedures  Procedure : Gloves Mask Gown Eye Protection  Control minor bleeding ; Yes No No No  Control major bleeding ; Yes Yes Yes Yes  Vital signs; No No No No

Primary Survey  The primary survey is a rapid head-to-toe assessment designed to identify and immediately correct life- and limb threatening injuries.  Within the first minute, you must determine if the person is critically injured and activate the emergency action plan (EAP).  The primary survey consists of five parts, a common mnemonic used to help remember these parts of the primary survey is simply the first five letters of the alphabet (ABCDE)

Parts of The Primary survey A: Stabilize cervical spine and check the airway. B: Check for breathing. C: Check for circulation. D: Check for neurological disability (or apply defibrillator). E: Check level of exposure.

Stabilize cervical spine and check the airway  Injury to the cervical spine is most common in accidents, so it should be find out first.  Stabilize the head and keep it in a neutral position with reference to the neck.  Now evaluate the airway and determine responsiveness.  It the person speaks in a clear and normal voice, you are assured the airway is patent.  If the person is unconscious, look and listen for signs of airway compromise such as snoring.  Either lifting the chin or using a modified jaw thrust maneuver with the cervical spine neutral, can relieve an airway obstruction.  Abnormal airway sounds such as gurgling or stridor indicate the presence of a possible foreign body that must be removed.

Stabilize cervical spine and check the airway The head tilt–chin lift method is used to open the airway occluded by the tongue. The jaw thrust maneuver is used to open the airway when a cervical spine injury is suspected.

Check for Breathing.  Look and feel for the chest to rise.  Look to see that the chest rises in a symmetrical fashion. Asymmetry may indicate significant chest trauma.  Evaluate the rate and quality of breathing.  A respiratory rate less than 8 or greater than 30 is significant and cause for concern.  The color of the oral mucosa and nail beds should be checked for cyanosis, which is a bluish color indicating hypoxia.  Breathing must be adequate to ensure oxygenation of tissues (ventilation).

Check for Circulation  Quickly feel the radial pulse and note if it is fast or slow, regular or irregular, and strong or weak.  If the radial pulse is absent, check the carotid pulse.  A weak or absent radial pulse is a strong indication that the person is in critical condition and mortality and morbidity are increased.  Capillary refill. Press on the nailed of any finger and quickly release, noting how quickly color returns. Color should return within 3 seconds or as quickly as you can say the words “capillary refill.”  If capillary refill is delayed, the person’s circulation is not sufficient to perfuse the vital organs.

Check for Neurological Disability (or apply defibrillator)  Disability refers to a brief neurological examination.  It is time consuming to perform a focused neurological examination, and merely asking the person to move his or her arms and legs is sufficient for a primary survey.  If the person is in cardiac arrest, the automatic external defibrillator should be used immediately.

Check Level of Exposure  Clothing or equipment may need to be removed to examine the injured person.  Modesty or environmental concerns should be taken into account but should never inhibit the examination.

Secondary Survey Examination  Starting at the head use a look, listen, and palpate approach.  Look for contusions, abrasions, lacerations, and deformity.  Listen to breath sounds in the chest. Palpate body parts for crepitus, pain, and rigidity or masses.  Listen for abnormal sounds while palpating.

Points to Be Remember  A physical examination has four components: inspection, palpation, percussion, and auscultation.  The primary survey is a rapid head-to-toe assessment designed to identify and immediately correct life- and limb-threatening injuries.  The primary survey includes five parts: stabilize cervical spine and check the airway, check for breathing, check for circulation, check for neurological disability (or apply defibrillator), and check level of exposure.  The secondary survey consists of a complete head-to- toe examination to rule out other injuries that may not be apparent on the primary examination.