1. Copyright © 2004, Mosby Inc. All rights reserved.

2. Detailed Physical Examination Chapter 12 Slide 1 Copyright © 2004, Mosby Inc. All rights reserved.

3. Case History Your ambulance responds to a pedestrian who was struck by a car. You determine the scene is safe to approach and find a 28-year- old female who is alert and oriented. There were no significant findings in the initial assessment and rapid trauma assessment. You are now ready to conduct your detailed physical examination en route to the hospital. Your ambulance responds to a pedestrian who was struck by a car. You determine the scene is safe to approach and find a 28-year- old female who is alert and oriented. There were no significant findings in the initial assessment and rapid trauma assessment. You are now ready to conduct your detailed physical examination en route to the hospital. Slide 2 Copyright © 2004, Mosby Inc. All rights reserved.

4. Detailed Physical Examination  More deliberate and comprehensive than the rapid trauma assessment  Conducted as patient is being transported to the hospital  Areas such as the face, eyes, nose, mouth, and ears are checked more closely Slide 3 Copyright © 2004, Mosby Inc. All rights reserved.

5. Detailed Physical Examination  Situation- and time- dependent  Depends on severity of patient’s condition  Example: Cardiac arrest »Attention devoted to CPR, use of an AED »EMTs are busy administering critical treatments »Detailed exam is not possible Slide 4 Copyright © 2004, Mosby Inc. All rights reserved.

6. Detailed Physical Examination  Injury-specific  May or may not be complete head-to-toe  Example: Ballplayer struck in the face »Detailed assessment of the eyes, nose, mouth, and ears »Assessment of abdomen or lower extremities may not be appropriate  Example: Victim of car crash »Detailed head-to-toe examination Slide 5 Copyright © 2004, Mosby Inc. All rights reserved.

7. Detailed Physical Examination  Usually performed en route to hospital  Responsive patients  May feel exam is a repeat  May view it as an invasion of privacy  Explain that you have only checked briefly for critical injuries; now need to examine in more detail  Ambulance provides a degree of privacy Slide 6 Copyright © 2004, Mosby Inc. All rights reserved.

8. Inspect and Palpate DCAP/BTLS  Deformities  Contusions  Abrasions  Punctures/penetrations  Burns  Tenderness  Lacerations  Swelling Slide 7 Copyright © 2004, Mosby Inc. All rights reserved.

9. Detailed Examination — Head  DCAP/BTLS  Pay attention to the scalp.  Wounds can be hidden by hair.  Injuries may not be obvious on quick inspection.  Gently palpate swollen areas of the head.  Avoid inadvertently depressing bone fragments onto the brain. Slide 8 Copyright © 2004, Mosby Inc. All rights reserved.

10. Detailed Examination — Face  DCAP/BTLS  Gently palpate facial bones.  Pay attention to the airway.  Facial injuries can cause airway compromise.  Aspiration is a major concern.  Make certain suction is available to deal with secretions. Slide 9 Copyright © 2004, Mosby Inc. All rights reserved.

11. Detailed Examination — Ears  DCAP/BTLS  Check inside and behind ears for signs of injury.  Battle’s sign  Discoloration behind the ear  May be a sign of a skull injury  Takes time to develop  Check for drainage of blood or blood-tinged cerebrospinal fluid.  If drainage is noted, apply loose dressing over ear. Slide 10 Copyright © 2004, Mosby Inc. All rights reserved.

12. Detailed Examination — Eyes  DCAP/BTLS  Inspect the eyes for injuries, discoloration, and foreign bodies  May be blood  Under the cornea  In the anterior chamber between the cornea and the iris  Behind the sclera  Inspect the pupils and note  Size  Equality  Response to light Slide 11 Copyright © 2004, Mosby Inc. All rights reserved.

13. Detailed Examination — Eyes  Closely examine penetrating injuries  Entire eye may be exposed  Small wound may be evident through which the fluid can escape.  Do not place pressure on the eyeball.  Especially if penetration is suspected Slide 12 Copyright © 2004, Mosby Inc. All rights reserved.

14. Detailed Examination — Nose  DCAP/BTLS  Note drainage or active bleeding.  May indicate skull injury  Nasopharyngeal airway should not be used. »May actually penetrate the brain space  If the patient has a burn injury  Note singed nasal hairs »May point to respiratory involvement  Bleeding from the nose may complicate airway.  Have suction ready. Slide 13 Copyright © 2004, Mosby Inc. All rights reserved.

15. Detailed Examination — Mouth  Examine for  Discoloration  Loose teeth  Foreign bodies  Risk of airway obstruction  Dentures can be left in place if they are stable.  Remove and save fragments of broken teeth since they may be re-planted. Slide 14 Copyright © 2004, Mosby Inc. All rights reserved.

16. Detailed Examination — Mouth  Tongue  Swollen (injury or allergic reaction)  Lacerations  Bites (seizure)  Check for odors.  Clues to medical or toxic problems »Examples o Alcohol o Acetone-like odor from diabetic patients  EMT is not expected to know the cause of the odor.  Describe the odor to medical direction and receiving hospital. Slide 15 Copyright © 2004, Mosby Inc. All rights reserved.

17. Detailed Examination — Neck  DCAP/BTLS  Crepitation  Subcutaneous emphysema  Jugular venous distention  Tracheal shift Slide 16 Copyright © 2004, Mosby Inc. All rights reserved.

18. Detailed Physical Examination — Chest  DCAP/BTLS  Breath sounds  Paradoxical breathing Slide 17 Copyright © 2004, Mosby Inc. All rights reserved.

19. Detailed Physical Examination — Abdomen  DCAP/BTLS  Firm vs. soft  Distended Slide 18 Copyright © 2004, Mosby Inc. All rights reserved.

20. Detailed Physical Examination — Pelvis  DCAP/BTLS  Crepitation  Tenderness  Motion Slide 19 Copyright © 2004, Mosby Inc. All rights reserved.

21. Detailed Physical Examination — Lower Extremities  DCAP/BTLS  Distal pulse Slide 20 Copyright © 2004, Mosby Inc. All rights reserved.

22. Detailed Physical Examination — Lower Extremities  Sensation  Motor function Slide 21 Copyright © 2004, Mosby Inc. All rights reserved.

23. Detailed Physical Examination — Upper Extremities  DCAP/BTLS  Distal pulse Slide 22 Copyright © 2004, Mosby Inc. All rights reserved.

24. Detailed Physical Examination — Upper Extremities  Sensation  Motor function Slide 23 Copyright © 2004, Mosby Inc. All rights reserved.

25. Detailed Physical Examination — Back  DCAP/BTLS  Look for exit wounds with penetrating trauma. Slide 24 Copyright © 2004, Mosby Inc. All rights reserved.

26. Summary  Detailed exam is more deliberate and comprehensive than the focused physical exam.  Detailed exam is performed during transport.  Areas such as the face, eyes, nose, mouth, and ears are checked more closely.  Perform detailed physical examination.  Check for signs of injury (DCAP/BTLS) in all body regions.  Maintain spinal immobilization.  Log-roll the patient to assess the posterior body. Slide 25 Copyright © 2004, Mosby Inc. All rights reserved.