U.S. ARMY MEDICAL DEPT.

CENTER & SCHOOL CORRESPONDENCE PHASE 91B BNCOC TECHNICAL TRAINING Assessment and Initial Management of the Trauma Patient I. REFERENCE.

M C2000190 0797

Campbell, J.E. (Ed.), Basic Trauma Life Support (Advanced). (3rd Ed.) Englewood Cliffs, N.J.: PrenticeHall Inc. 1995. II. OBJECTIVES. A. Terminal Learning Objective. Given a trauma patient scenario, assess and prioritize critical conditions in a trauma patient and state critical information IAW cited reference. B. Enabling Learning Objectives. 1. 2. 3. 4. III. Given a list, identify the stages of an ambulance call IAW cited reference. Given a list, identify the preliminary actions that should be performed prior to approaching a patient IAW cited reference. Given a list, identify patient trauma assessment and management priorities for primary, secondary, and critical reassessment IAW cited references. Given a list, identify patient assessment actions using the priority plan IAW cited references.

EXPLANATION.

Objective 1. Given a list, identify the stages of an ambulance call IAW cited reference. A. Stages of an Ambulance Call. 1. Predispatch a. Predispatch time should be spent either sleeping, training, or performing equipment maintenance. This predispatch time is the most overlooked stage of prehospital care. The inability to find an address can waste more time than disorganized patient assessment - both can be fatal to the patient..

b. 2.

Dispatch. For a rapid response, the rescue crew must have the proper and correct information. a. b. Details and exact nature of the call - what occurred, number of victims, scene dangers, and special equipment to be transported. Precise location of the call - get directions that are as accurate as possible.

M C2000190 0797 c. 3. 4. Call-back number - if you have trouble locating the scene of the accident this number becomes invaluable. The unit can contact the scene while en route.

Travel to the accident scene - a call back can provide decisions about additional units and equipment needed. Scene actions. a. b. c. Safety at the scene. Upon arrival assess quickly the overall situation. Evaluate, resuscitate, and prepare the patient.

5.

Transporting to the hospital. a. b. c. According to local protocols, select the most suitable hospital and route. The most experienced provider should remain at the patients side to provide interventions and continuous monitoring. If the patients condition deteriorates during transport, notify Medical Direction. Relay estimated arrival time (ETA) and special needs to the receiving facility.

M C2000190 0797 6. Actions at the hospital. a. b. Continue patient care until the medical facility staff assumes responsibility. Do Not leave a patient unattended. Relay pertinent patient information to the facility medical personnel - describe the accident, mechanisms of injuries, observed and suspected injuries, procedures performed, and changes in condition. Remain as long as needed.

B. Objective 2.

Trauma Assessment. Given a list, identify the preliminary actions that should be performed prior to approaching a patient IAW cited reference. 1. Preliminary scene actions. a. b. Scene survey - look for scene hazards. Do Not enter if the scene is not safe. Note the number of patients - call for another ambulance if more than one patient. Notify Medical Direction to initiate the disaster protocol if there are numerous casualties. Initiate patient accountability. What is the the mechanism of injury? Is special extrication and equipment needed?

c. d. 2.

Essential equipment - all essential equipment should be carried to the scene. This prevents valuable loss of time returning to the vehicle. The following equipment is always needed for trauma patients: a. b. c. d. e. Long board with attached head immobilization device. Cervical immobilization device. Oxygen and airway equipment (include suction). Trauma box. Personal protection equipment.

Objective 3.

Given a list, identify patient trauma assessment and management priorities for primary, secondary and critical care reassessment IAW cited reference. 3. Assessment and management priorities (patient). a. Primary trauma survey - rapid assessment to determine life-threatening conditions. Complete in 2 minutes or less. Airway obstruction or cardiac arrest will interrupt this assessment. Control major bleeding. (1) Assessment priorities.

M C2000190 0797 (a) (b) (c) (d) (e) (2) While approaching, conduct a total overview of the patient. Evaluate airway, C-spine control, and initial level of consciousness (LOC). Evaluate breathing. Evaluate circulation. Examine abdomen, pelvis, and extremities.

Interventions and transport decision - based on primary survey, decide if a critical situation is present. Transport patients with critical trauma immediately - treatment will be done during transport. Interventions that should be done on the scene include removal of airway obstruction, stop major bleeding, seal sucking chest wounds, hyperventilate, decompress tension pneumothorax, etc. Most of the treatment should wait until transport has begun.

b.

Secondary trauma survey - rapid, detailed evaluation to determine injuries (obvious and potential). Keep under 5 minutes. Assessment priorities are: (1) (2) (3) (4) (5) Vital signs. Patient history and trauma event. Head-to-toes exam (including neurological). Additional bandaging and splinting. Continuous monitoring.

c.

Reassessment and critical care - critical procedures performed on scene and during transport, the reassessment survey, and medical direction communication. Assess for changes in the patients condition: (1) (2) (3) (4) (5) (6) (7) Level of consciousness. Airway exam. Breathing. Pulse, blood pressure, skin color/temperature. Abdomen exam. Focused assessment of injuries. Check of interventions.

Objective 4.

Given a list, identify patient assessment actions using the priority plan IAW cited reference. 4

M C2000190 0797 4. Assessment of patient - priority plan. a. Primary survey. (1) Total overview of the patient situation while approaching the patient. Is patient alert or in obvious distress, are there major injuries which are obvious? DO NOT vary how the primary survey is performed skipping steps can mean missed injuries. Evaluate airway, c-spine control, initial level of consciousness. Extrication must not interfere with patient care. Open airway before finishing the primary survey. NEVER extend the neck to open the airway of a trauma patient (spinal injury danger). Assess breathing and circulation. If there is no pulse, begin cardiopulmonary resuscitation. Evaluate skin color/temperature - early assessment of circulatory status and the presence of shock. Check for injury to the neck. Evaluate the chest. Are breath sounds are present and equal bilaterally? Assess for a tension pneumothorax or a hemothorax. Observe any chest deformities, contusions, abrasions, penetrations, paradoxical movement, burns, lacerations, and swelling (DCAPP-BLS) Feel for instability, tenderness, and crepitation (TIC). Examine abdomen, pelvis, and extremities. Expose the abdomen observe distension, contusions, abrasions, and penetrations. Palpate quadrants. Assess pelvis - feel for TIC. Check both legs and arms and for pulse, motor function, and sensation (PMS). Stop active bleeding and report excessive bleeding to the receiving physician.

(2)

(3)

(4)

(5)

WARNING: DO NOT USE CLAMPS TO STOP BLEEDERS - THIS MAY CAUSE INJURIES TO OTHER STRUCTURES. NOTE: Enough information has been obtained at this stage to determine critical trauma situations that should be treated by load and go. b. Critical interventions and transport decision - is the patient in a load- and-go category? Critical conditions or injuries must be determined: (1) (2) (3) (4) Head injury with decreased level of consciousness. Airway obstruction unrelieved by mechanical methods (suction, forceps). Conditions resulting in inadequate breathing - large open chest wound, large flail chest, tension pneumothorax, major blunt chest injury. Traumatic cardiopulmonary arrest.

M C2000190 0797 (5) Shock - hemorrhagic, spinal, myocardial contusion, pericardial tamponade.

NOTE: Conditions based on signs and symptoms: - Decreased level of consciousness - Abnormal respiration - Abnormal circulation (shock) - Signs of conditions that rapidly lead to shock - tender, distended abdomen, pelvic instability, bilateral femur fractures c. Secondary survey - for a critical patient perform during transport. A stable patient should have this exam done at the scene - overall scene time should be under 10 minutes. (1) (2) Record vital signs. Obtain a history of the injury - SAMPLE history from conscious patient (symptoms, allergies, medications, past medical history, last oral intake). Perform a head-to-toes exam in detail - inspection, auscultation, palpation, and percussion. Complete a brief neurological exam - level of consciousness, motor, sensation, pupils (using AVPU). Complete bandaging and splinting. Continue monitoring/reevaluating the patient.

(3) (4) (5) (6)

NOTE: If the secondary survey reveals critical trauma situations, transport immediately. d. Critical care and reassessment exam - all the interventions and procedures performed in response to on-scene assessments and during transport. The reassessment exam should be performed: for critical patients every 5 minutes, for stable patients, every 15 minutes, anytime the patients condition worsens. (1) (2) (3) (4) Manage airway - administer oxygen to all critical trauma patients. Apply monitor(s) (usually done during transport). Make I.V. decisions (always done during transport). Bandage and splint.