0. International Trauma Life Support, 7e
Trauma Assessment and Management 2
Key Lecture Points
The concept of simultaneous assessment (team leader) and delegated intervention (team members) in life-threatening emergencies needs to be stressed.
Point out that the Initial Assessment is interrupted only for airway obstruction, when the scene becomes too dangerous, or the need to perform CPR.
The step-by-step assessment scheme must be taught.
Emphasize the need to get the critically injured patient out of the field and to an appropriate hospital as quickly as possible. The 10-minute rule must be reinforced.
Stress that the Ongoing Exam should be repeated any time the patient's condition changes.

1. Trauma Assessment and Management
NOTE: Remember ITLS Primary Assessment and ITLS Secondary Assessment are taught in skill stations.
Courtesy of ITLS Ontario, Steve McNenly, Jennifer Lundren, and Sheryl Jackson

2. Overview ITLS Patient Assessment Initial Assessment related to
Primary Survey
Ongoing Exam
Secondary Survey
Initial Assessment related to
Rapid Trauma Survey vs. Focused Exam
Interruptions
Critical conditions and the “Fix It” process

3. ITLS Patient Assessment
ITLS Primary Survey
Scene Size-up
Initial Assessment
Rapid Trauma Survey vs. Focused Exam
ITLS Ongoing Exam
ITLS Secondary Survey
IMAGE: Figure 2-1 ITLS Patient Assessment.
NOTE: Use flowchart miniature to conceptualize and demonstrate how parts of Assessment fit together. You begin in same place for all patients, decision takes you on different paths, but come back to same for all patients. (Students do not need to be able to read flowchart on screen.)
NOTE: (U.S.) ITLS patient assessment (Primary Survey, Secondary Survey, and Ongoing Exam) is consistent with U.S. Department of Transportation guidelines.
FLOWCHART:
(Top box—STEP for all patients) ITLS Primary Survey starts with Scene Size-up. If scene is safe to enter, moves on to next STEP.
(Second box—STEP for all patients) Initial Assessment is VERY BRIEF exam of level of consciousness and ABCs, moves to next STEP.
(Top diamond—DECISION splits group) Mechanism of Injury DECISION and information obtained in first two steps, go one of two directions and perform either Rapid Trauma Survey or Focused Exam.
(Left branch—STEP) Rapid Trauma Survey is RAPID head-to-toe exam to determine if immediately life-threatening conditions exist and to identify those patients who should have immediate transport.
(Right branch—STEP) Focused Exam is limited to area of injury.
(Both branches come back to center diamond for DECISION) Based on situation:
DECISION to perform or not perform ITLS Secondary Survey step.
DECISION to perform or not perform ITLS Ongoing Exam step.
(Bottom left box—STEP) ITLS Secondary Survey in that Secondary Survey is an evaluation for all injuries, not just life-threatening ones.
(Bottom right box—STEP) ITLS Ongoing Exam is meant to identify changes in patient's condition.
ITLS Secondary Survey and ITLS Ongoing Exam steps can be performed as needed.

4. “Fix It” ITLS Primary Survey ITLS Primary Survey Scene Size-up
Initial Assessment
Rapid Trauma Survey vs. Focused Exam
IMAGE: Figure 2-2 ITLS Primary Survey.
The purpose of the Primary Survey is to determine if immediately life-threatening conditions exist and to identify those patients who should have immediate transport to the hospital.
“Fix It”

5. “Fix It” Delegate immediate interventions to partners
Do not stop your assessment unless
Scene becomes unsafe
Airway obstruction
Cardiac arrest
Teamwork
Assessment
“Fix It”
Teamwork
Experience has shown that most mistakes occur because the team leader stops to perform an intervention and forgets to perform part of the assessment.
Delegate interventions to your team members while you continue the assessment.
This is an important concept that immediately addresses problems encountered and yet does not interrupt the assessment sequence and does not increase scene time.
This is what teamwork is all about.
Fix It
Interventions performed based on patient needs, resources available and time it will take to execute. Performed by team members during assessment phases without causing interruptions of the assessment.

6. Scene Size-up IMAGE: CALLOUT from ITLS Primary Survey.
NOTE: Use miniature to conceptualize and demonstrate how survey is a series of steps to be done in sequence without deviation. (Students do not need to be able to read steps on screen.)
NOTE: The next series of slides steps through Rapid Trauma Survey. Remember: this skill will be taught in skill stations. Don't over lecture.
Rapid Trauma Survey is a brief exam done to find all life-threats.

7. Scene Size-up Hazards PPE Number of patients MOI
Power lines, gas, animals, people
PPE
Number of patients
Establish command
Additional resources?
MOI
Anticipate type and severity of injuries
NOTE: Scene Size-up has already been discussed; will not repeat details here.
NOTE: Click on the screenshot in presentation mode to play the Video clip “ITLS7e Scene Survey” in a browser window. Close the browser window to return to the presentation.
It cannot be stressed too much that failure to perform preliminary actions can jeopardize lives . Perform Scene Size-up as described in Chapter 1.
If there are more patients than your team can effectively handle, triage them rapidly utilizing Triage Decision Tree and initiate MCI protocols. (See Chapter 1 and also Multicasualty Incidents and Triage under Additional Resources on Resource Central.)
The Scene Size-up will set stage for how you will perform rest of ITLS Primary Survey.

8. Initial Assessment
IMAGE: CALLOUT from ITLS Primary Survey (Figure 2-4).
NOTE: Use miniature to conceptualize and demonstrate how survey is a series of steps to be done in sequence without deviation. (Students do not need to be able to read steps on screen.)
NOTE: The next series of slides steps through Rapid Trauma Survey. Remember: this skill will be taught in skill stations.
Rapid Trauma Survey is a brief exam done to find all life-threats.

9. ITLS Primary Survey Initial Assessment Prioritize patient
General impression
Level of consciousness
Manual stabilization of cervical spine
ABCs
Prioritize patient
Identify immediate life-threatening conditions
NOTE: Click on the screenshot in presentation mode to play the Video clip “ITLS7e Initial Assessment” in a browser window. Close the browser window to return to the presentation.
Once scene is safe to enter, team leader must focus on rapid assessment.
All decisions on treatment require that you have identified life-threatening conditions.
If immediate interventions are needed, delegate them to your team members while you continue assessment.
Experience has shown that most mistakes occur because team leader stops to perform an intervention and forgets to perform part of assessment.
Team approach makes most efficient use of time and allows you to rapidly perform Initial Assessment without performing noninvasive airway interventions yourself, which can interrupt your thought process.
Purpose of Initial Assessment is to prioritize and determine existence of immediately life-threatening conditions. Information gathered is used to make decisions about critical interventions and time of transport.
Initial Assessment is made up of general impression upon approaching patient, an evaluation of level of consciousness (LOC), manual stabilization of cervical spine (if needed), and assessment of airway, breathing, and circulation (ABCs).

10. ITLS Primary Survey “Fix It” Less than 2 minutes
Initial Assessment and Rapid Trauma Survey
Delegate any intervention
Interrupt survey only for:
Unsafe scene
Airway obstruction
Cardiac arrest
“Fix It”
Initial Assessment and Rapid Trauma Survey combined should take less than 2 minutes.
Remember, once you begin ITLS Primary Survey, only 3 things should cause you to interrupt completion of assessment:
Scene becomes unsafe.
Must treat an airway obstruction.
Must treat cardiac arrest.
All other problems (such as respiratory arrest or dyspnea) may be addressed by team members.
Stopping during survey causes you to overlook essential items.
For critical patients, goal should be to have on-scene times of 5 minutes or less. While interventions may be important, only thing proven to increase survival of trauma patients is decreasing time to definitive care (trauma center).

11. ITLS Primary Survey General impression Triage multiple patients
Obvious major injuries or bleeding – immediately control life-threatening bleeding
Approximate age, sex, weight
General appearance
Position of patient body and surroundings
Patient activity
Triage multiple patients
On approach, note patient's approximate age, sex, weight, and general appearance.
Old and very young are at increased risk.
Female patients may be pregnant.
Observe position of patient.
Body position and position in relation to surroundings
Note activity. (Is patient aware of surroundings, anxious, obviously in distress, etc.?)
Any obvious major injuries or major bleeding?
Observation of patient in relation to scene and mechanism of injury will help you prioritize.
If there are multiple patients, rapidly triage them and begin evaluation of most seriously injured patient first.

12. U P V A ITLS Primary Survey Alert Unresponsive
Initial Level of Consciousness
Cervical-spine stabilization
Alert
Responds to Verbal stimuli
Responds to Pain
Unresponsive U P V A
Try to approach from front so patient does not try to turn head.
Assessment begins immediately, even if patient is being extricated.
As team leader, try to approach patient from front (face to face, so patient does not turn head to see you).
If there is a mechanism of injury that suggests spinal injury, immediately and gently but firmly stabilize head and neck in a neutral position (this can be delegated to a team member).
Stabilize head and neck in position found:
If head or neck is held in an angulated position and patient complains of pain on any attempt to straighten it.
If patient is unconscious and neck is held to one side and does not move when you gently attempt to straighten it.
Speak to patient and ask a question such as, “Can you tell me what happened?”
Reply gives immediate information about both airway and level of consciousness.
If responds appropriately to questioning, you can assume that airway is open and level of consciousness (LOC) is normal.
If response is not appropriate, make a mental note of LOC using AVPU scale.
Anything below “A” (alert) should trigger a systematic search for causes during Rapid Trauma Survey.

13. “Fix It” ITLS Primary Survey Airway: look, listen, feel
Direct: simple positioning and suctioning
If not adequate
“Fix It”
If cannot speak or is unconscious, further evaluation of airway should follow.
Look, listen, and feel for movement of air.
Position airway as needed.
Avoid extending neck to open airway if trauma suspected.
If airway obstructed (apnea, snoring, gurgling, stridor), use an appropriate method (reposition, sweep, suction) to open it immediately.
Failure to quickly provide an open airway is one of three reasons to interrupt patient assessment part of ITLS Primary Survey.
If simple positioning and suctioning fail to provide an adequate airway, or if stridor is present, advanced airway techniques may be necessary immediately.
© Pearson

14. “Fix It” ITLS Primary Survey Breathing: look, listen, feel
Direct: high-flow oxygen
If not adequate
“Fix It”
Look, listen, and feel for movement of air.
If unconscious, place your ear over patient's mouth so you can judge both depth and rate of ventilations.
Look at movement of chest (or abdomen), listen to sound of air movement, and feel both movement of air on your cheek and movement of chest wall with your hand.
Notice if patient uses accessory muscles to breathe.
If ventilation is inadequate (less than 8 per minute or too shallow), direct team member to assist ventilation immediately.
Ensure adequate ventilatory rate and adequate volume.
Monitor ventilation with capnography (recommended).
ETCO2 at about 35
If breathing too fast, administer supplemental high-flow oxygen.
As a general rule, all patients with multi-system trauma should receive supplemental high-flow oxygen.
© Pearson

15. Respiratory Rates Normal Abnormal Adult 10–20 <10 and >24 Child
15–30
<15 and >35
Infant
25–50
<25 and >60

16. ITLS Primary Survey Major bleeding controlled?
“Fix It”
Circulation: peripheral pulse
No peripheral, check carotid
Too fast, too slow, quality
Interrupt: cardiac arrest
Skin
Color, temperature, condition
Note rate and quality of pulses at wrist (brachial in infant).
Checking pulse in neck is not necessary if awake and alert or has a palpable peripheral pulse.
Quickly note whether rate is too slow or too fast, and note quality (thready, bounding, weak, irregular).
Remember, pulse rate is checking to determine how well blood is circulating and if sufficient for good perfusion.
Is it too fast for good perfusion? (>120 in an adult)
Is it too slow for good perfusion? (<60 in an adult)
It is not a determination of tachycardia or bradycardia
If pulse absent at neck, immediately start CPR (unless there is massive blunt trauma) and prepare for immediate transport
One of three reasons to interrupt assessment during ITLS Primary Survey
At wrist, note skin color, temperature, and condition (and capillary refill in an infant or small child)
Pale, cool, clammy skin; thready radial pulse; and decreased LOC are best early assessments of decreased perfusion (shock)
Direct control of bleeding.
© Pearson

17. MOI Decision Dangerous generalized or unconscious Dangerous focused
Rapid Trauma Survey
Dangerous focused
Focused Exam
No significant MOI Initial Assessment normal
If dangerous generalized mechanism of injury or if unconscious:
Perform Initial Assessment and go directly to Rapid Trauma Survey.
Perform interventions, transport, Ongoing Exams, and possibly a Secondary Survey en route.
If dangerous focused mechanism of injury suggesting an isolated injury:
Perform Initial Assessment and Focused Exam limited to area of injury.
Full Rapid Trauma Survey is not required.
Perform interventions, transport, Ongoing Exams, and possibly a Secondary Survey.
If no significant life threat in mechanism of injury:
Perform Initial Assessment and, if normal:
Directly to a Focused Exam based on chief complaint.
Secondary Survey would not be necessary.
© Mikael Damkier

18. Rapid Trauma Survey IMAGE: CALLOUT from ITLS Primary Survey.
NOTE: Use miniature to conceptualize and demonstrate how survey is a series of steps to be done in sequence without deviation. (Students do not need to be able to read steps on screen.)
NOTE: The next series of slides steps through Rapid Trauma Survey. Remember: this skill will be taught in skill stations.
Rapid Trauma Survey is a brief exam done to find all life-threats.

19. Rapid Trauma Survey Assess Transfer to backboard Head and neck Chest
Abdomen
Pelvis
Lower and upper
extremities
Back
Transfer to backboard
NOTE: Click on the screenshot in presentation mode to play the Video clip “ITLS7e Rapid Trauma Survey” in a browser window. Close the browser window to return to the presentation.
NOTE: Remember: this skill will be taught in detail in skill stations.
Inspect head and neck (look and feel)
Major facial injuries, bruising, swelling, penetrations, subcutaneous emphysema
Neck vein distention? Tracheal deviation?
Assessment of neck is a continuation of breathing and circulation by checking for JVD, tracheal deviation, and subcutaneous emphysema.
A rigid cervical extrication collar may be applied at this time.
Inspect chest—expose and look, feel, and listen
Asymmetry, contusion, penetrations, paradoxical motion, instability, crepitation
Note if ribs rise with respiration or if there is only diaphragmatic breathing. Look for signs of blunt trauma or open wounds. Feel for tenderness, instability, and crepitation (TIC).
Breath sounds —listen
Present? Equal?
Listen with stethoscope over lateral chest about fourth intercostal space in midaxillary line on both sides.
If unequal: percussion
If breath sounds are not equal (decreased or absent on one side), percuss chest to determine whether patient is just splinting from pain or if a pneumothorax or a hemothorax is present.
Heart tones
Very briefly notice heart sounds so you will have a baseline for changes such as development of muffled heart sounds.
If abnormalities are found during chest exam (open chest wound, flail chest, tension pneumothorax, hemothorax), delegate appropriate intervention (seal open wound, stabilize flail, decompress severe tension pneumothorax).
Abdomen
Expose and look: bruising, penetration/evisceration
Gently palpate: tenderness, rigidity, distention
Pelvis
Tenderness, instability, crepitation
Look for deformity or penetrating wounds.
Feel for tenderness, instability, and crepitation by gently pressing down on symphysis and gently squeezing in on iliac crests.
Note that tenderness is not same thing as being unstable. The pelvis may be tender and yet stable.
If pelvis is unstable, you can feel pelvic ring collapse as you apply pressure. If pelvis is unstable, do not check again!
Lower/upper extremities
Swelling, deformity, instability, motor, sensory
Assess both upper legs, looking for deformity and feeling for TIC.
Remember that bilateral femur fractures can produce enough internal blood loss to be life threatening.
Scan for obvious wounds or deformities of arms and lower legs.
Note whether patient can move fingers and toes before transferring to backboard.
Place patient on backboard.
Transfer patient to a long backboard, checking posterior of patient as you do this.
If patient has an unstable pelvis or bilateral femur fractures, to prevent further injuries, use a scoop stretcher (Figure 2-5) to transfer patient to a long backboard.

20. If critical situation, transfer to ambulance to complete exam.
Rapid Trauma Survey
If critical situation, transfer to ambulance to complete exam.
© Pawel Nawrot

21. Rapid Trauma Survey Obtain baseline vital signs
If altered mental status
Brief neurological exam
Pupils, GCS, and signs of cerebral herniation
Look for medic alert tags
Consider other causes
Baseline vital signs
Measured pulse, respirations, blood pressure.
Obtain baseline vital signs and rest of SAMPLE history.
Vital signs and SAMPLE should be done during transport for critical patients.
Pupils
Size? Reactive? Equal?
If altered mental status:
Brief neurological exam
Identify possible increased intracranial pressure (ICP).
Includes pupils, Glasgow Coma Scale (GCS) score, and signs of cerebral herniation.
Always performed during transport.
Finger-stick glucose performed at beginning of transport.
Glasgow Coma Scale Score
Eyes, voice, motor, orientation, emotional state.
Look for medical identification devices.
Consider nontraumatic causes of altered mental status.

22. Glasgow Coma Scale *Decorticate posturing to pain
IMAGE: Table 2-4 Glasgow Coma Scale Score
NOTE: Also referred to either as Glasgow Coma Scale or Glasgow Coma Score.
Very important to do this as a baseline; how it changes is of critical importance.
It is done at END of Rapid Trauma Survey (if altered mental status).
It is done early in Secondary Survey.
*Decorticate posturing to pain
**Decerebrate posturing to pain

23. Priority Patient Dangerous MOI History High Risk Groups
Loss of consciousness
High Risk Groups
Abnormal Initial Assessment
Altered mental status
Difficulty breathing
Abnormal perfusion
NOTE: High-risk group (such as very young, very old, chronically ill).
NOTE: Notice importance of breathing. Difficulty breathing appears in both groups.
Load-and-go patients include:
Dangerous mechanism of injury
History that reveals:
Loss of consciousness
Difficulty breathing
Severe pain of head, neck, or torso
High-risk group (such as very young, very old, chronically ill)
Altered mental status
Abnormal perfusion
Any abnormality revealed during Initial Assessment
© Pawel Nawrot

24. Brief Targeted History
S Symptoms
A Allergies
M Medications
P Past medical history
L Last oral intake
E Events preceding incident
At same time as you are performing patient assessment part of ITLS Primary Survey, you or a team member obtain a brief target history (including SAMPLE history) from patient and from bystanders.
A more detailed history may be taken later during ITLS Secondary Survey.
Especially important:
If information must be gathered from bystanders, since they will not be available to question once transport is initiated.
If patient has loss of consciousness during transport.

25. Load-and-Go Situations
Initial Assessment
Altered mental status
Abnormal respiration
Abnormal circulation
Shock potential
Abnormal chest exam
Tender, distended abdomen
Pelvic instability
Bilateral femur fractures
NOTE: Significant mechanism of injury and/or poor general health has been added to “Load-and-Go” criteria.
Upon completion of Initial Assessment and Rapid Trauma Survey or Focused Exam, enough information is available to decide if a critical situation is present. Patients with critical trauma situations are transported immediately. Most treatment interventions will be done during transport.
If any of following critical injuries or conditions exist, transport immediately.
Initial Assessment reveals:
Altered mental status
Abnormal respiration
Abnormal circulation (shock or uncontrolled bleeding)
Signs discovered during Rapid Trauma Survey of conditions that rapidly lead to shock:
Abnormal chest exam (flail chest, open wound, tension pneumothorax, hemothorax)
Tender, distended abdomen
Pelvic instability
Bilateral femur fractures
Significant mechanism of injury and/or poor general health of patient:
As you consider mechanisms, age, general appearance, chronic illnesses, and so on, you may decide that patient is at higher risk than ITLS Primary Survey alone would suggest.
These higher-risk patients should go to a trauma center even though they might not meet other criteria to go there.
Remember that there are more considerations than just physical exam of patient.
Significant MOI and/or poor general health

26. When in doubt—transport early!

27. Critical Interventions
“Fix It”
Manage airway
Assist ventilation
Administer oxygen
Begin CPR
Control major external bleeding
Seal sucking chest
Stabilize flail chest
Decompress tension pneumothorax
Stabilize impaled object
Complete packaging
NOTE: These will be discussed in other lectures. Do not spend time teaching techniques now. Emphasize that only procedures done on scene directly relate to components of ITLS Primary Survey.
These “Fix Its” are done at scene, and most of them can be delegated to team members to perform while you continue ITLS Primary Survey.
Patient may be in a state of compensated shock; anticipate needs.

28. Initiate Transport Procedures not on scene, not lifesaving
Splinting, bandaging, IV line insertion
Elective intubation
Contact medical direction
As early as possible
Estimated time of arrival (ETA)
Condition of patient
Special needs on arrival
Procedures that are not lifesaving, such as splinting, bandaging, insertion of IV lines, or even emergency endotracheal intubation, must not hold up transport of critical patient.
If BVM ventilation is sufficient to transfer to ambulance and initiate transport, perform endotracheal intubation in transit.
At this point, ITLS Primary Survey is over and team leader may help other rescuers with patient care.
It is extremely important to contact medical direction as early as possible with critical patients.
It takes time to get appropriate surgeon and operating room team in place, and critical patient has no time to wait.
Always notify receiving facility of your estimated time of arrival (ETA), condition of patient, and any special needs on arrival.

29. ITLS Ongoing Exam Change in condition Perform and record Patient
Interventions
Perform and record
Critical: every 5 minutes
Stable: every 15 minutes
Each time patient moved
With each intervention
If condition changes
IMAGE: Figure 2-1 ITLS Patient Assessment.
Ongoing assessment and management include critical procedures performed on scene and during transport and communication with medical direction.
Ongoing Exam is abbreviated exam to assess for changes in condition.
Concentrate on reassessing only those things that may change.
In contrast to ITLS Secondary Survey, which is performed only once, Ongoing Exam may be performed multiple times during a long transport.

30. Ongoing Exam Subjective changes Mental status (LOC and pupils) ABCs
Neck, chest, abdomen
Previously identified injuries
Interventions
NOTE: Video clip “ITLS7e Ongoing Exam” will play as a loop (no sound) until next click.
NOTE: Click on the screenshot in presentation mode to play the Video clip “ITLS7e Ongoing Exam” in a browser window. Close the browser window to return to the presentation.
Ask the patient if there have been any changes in how she feels. Complete the SAMPLE history if not already done.
Reassess mental status (LOC and pupils). If the patient has an altered mental status, check a finger-stick glucose and recheck the GCS.
Reassess the ABCs.
Reassess the airway.
Recheck patency.
If this is a burn patient, assess for signs of inhalation injury.
Reassess breathing and circulation.
Recheck vital signs.
Note skin color, condition, and temperature.
Check the neck for jugular venous distention (JVD) and tracheal deviation. (If a cervical collar has been applied, remove the front to examine the neck.)
Recheck the chest. Notice the quality of breath sounds. If breath sounds are unequal, evaluate for splinting, pneumothorax, and hemothorax. Listen to the heart to see if the sounds have become muffled.
Reassess the abdomen, if mechanism suggests possible injury. Note the development of tenderness, rigidity, or distention.
Check each of the identified injuries (lacerations for bleeding, PMS distal to all injured extremities, flails, pneumothorax, open chest wounds, and so on).
Check interventions.

31. ITLS Secondary Survey IMAGE: Figure 2-6 ITLS Secondary Survey.
NOTE: Use miniature to conceptualize and demonstrate how survey is a series of steps to be done in sequence without deviation. (Students do not need to be able to read steps on screen.)
NOTE: The next series of slides steps through Rapid Trauma Survey. Remember: this skill will be taught in skill stations.
Rapid Trauma Survey is a brief exam done to find all life-threats.

32. ITLS Secondary Survey More comprehensive exam Performed
Evaluation for all injuries, not just life-threatening
Establishes baseline for treatment decisions
Performed
Critical patients—done during transport
Short transport—may not have time
Noncritical patients—done on scene
NOTE: ITLS Secondary Survey is taught in skill station.
ITLS Secondary Survey
More comprehensive exam to identify all injuries, not just life-threatening.
Establishes baseline from which treatment decisions will eventually be made.
Important to record information discovered.
Whether or not to perform a Secondary Survey as well as when to perform one depends on situation.
Critical patients should have this assessment done during transport rather than on scene.
Although we say Secondary Survey should be done on critical patients during transport, we have to apply a little common sense. More accurately, we should say “do not delay scene time of a critical patient.” If you are unable to transport, e.g., are waiting for an ambulance/helicopter or patient is being extricated, a Secondary Survey may be performed on scene.
If there is a short transport and you must perform interventions, you may not have time to do Secondary Survey.
If Primary Survey does not reveal a critical condition, Secondary Survey may be performed on scene.
Transport immediately if ITLS Secondary Survey reveals development of any critical trauma situations.

33. ITLS Secondary Survey Initial Assessment Vital signs Detailed Exam
Repeat routinely
Vital signs
Monitoring
Detailed Exam
Head-to-toe
DCAP-BLS-TIC
NOTE: Click on the screenshot in presentation mode to play the Video clip “ITLS7e Secondary Survey” in a browser window. Close the browser window to return to the presentation.
NOTE: ITLS Secondary Survey is taught in skill station.
Although we say Secondary Survey should be done on critical patients during transport, we have to apply a little common sense. More accurately, we should say “do not delay scene time of a critical patient.” If you are unable to transport, e.g., are waiting for an ambulance/helicopter or patient is being extricated, a Secondary Survey may be performed on scene.
DETAILED EXAM of complaints and previously found injuries
Exam consists of inspection, auscultation, palpation, and sometimes percussion.
Patient history—info not obtained in Primary
Complete SAMPLE history
Vital signs—repeat routinely
Measured pulse, respirations, blood pressure
Pulse oximeter (SpO2), cardiac monitor (ECG), blood sugar, CO2 monitor (ETCO2)
Glasgow Coma Scale Score
Eyes, voice, movement, emotional state
Head
Pupils, Battle's sign, raccoon eyes, drainage; deformities, contusions, abrasions, penetrations, burns, lacerations, swelling, tenderness, instability, crepitation (DCAP-BLS-TIC)
Neck
DCAP-BLS-TIC; neck vein distention? Tracheal deviation?
Chest
Asymmetry; paradoxical motion; DCAP-BLS-TIC
Breath sounds
Present? Equal?
If unequal: percussion
Heart tones, abdomen
DCAP-BLS-TIC; rigidity, distention
Pelvis
DCAP-BLS-TIC
Lower/upper extremities
DCAP-BTLS-TIC; PMS
Posterior
Examine only if not done in ITLS Primary Survey (DCAP-BLS-TIC)
At conclusion, finish bandaging and splinting.

34. Detailed Exam: DCAP-BLS-TIC
Deformities
Contusions
Abrasions
Penetrations
Burns Lacerations Swelling
Tenderness
Instability
Crepitus

35. Adjuncts for Patient Assessment
Pulse oximetry
Wave form capnography

36. Adjuncts for Patient Assessment
Serum lactate
Marker for tissue hypoxia
Finger-stick serum levels
Further studies needed
Portable ultrasound
F.A.S.T.
Serum lactate is a marker for tissue hypoxia and has been used in the hospital setting to monitor critical patients.
In the field it appears to be useful to predict which patients with normal vital signs are having occult internal bleeding and will soon develop hemorrhagic shock.
Services have been using prehospital finger-stick serum lactate levels to predict who will develop shock.
If further studies confirm its predictive value, it will very useful.
Portable ultrasound can be used to assess for intraabdominal hemorrhage and cardiac tamponade among other things.
Abdominal trauma sonography is very commonly used in the initial assessment of trauma patients in the emergency department and is called the FAST exam (focused assessment with sonography in trauma).
It is noninvasive and only takes from one to three minutes to perform.

37. Summary ITLS Patient Assessment Remain calm Key to trauma care
Not difficult, but time-critical
Rapid, orderly, thorough
Remain calm
Maximize speed through organization and teamwork