Assessment And Initial Management
-
Upload
posadashazel -
Category
Business
-
view
2.955 -
download
3
Transcript of Assessment And Initial Management
1
Assessment and Initial Assessment and Initial Management of the Management of the
Trauma PatientTrauma Patient
2
INTRODUCTIOINTRODUCTION
• Rapid systematic assessment is the key
• Interventions identified as lifesaving measures are initiated immediately
• A-B-C’s - first step in initial assessment
3
SCENE SCENE SIZE-UPSIZE-UPCOURTESY OF BONNIE MENEELY, R.N.
4
SCENESCENE SAFETY/ SECURITY SAFETY/ SECURITY
• Medic situational assessment differs from civilian scene size-up.
• Centers around an awareness of the tactical situation and current hostilities.
• Examine Battlefield:
– Determine zones of fire
– Routes of access and egress– Casualties occur over time changing
demands
5
CARE UNDER FIRECARE UNDER FIRE• What care can be offered at
casualty’s side
• Effects of movement, noise, and light
• Movement to safety
• Cover and Concealment
6
ENTERING A FIRE ENTERING A FIRE ZONEZONE
• Seek cover and concealment
• Survey for small arms fire
• Detect for fire or explosives
• Determine NBC status
• Survey structures for stability
7
MOVING CASUALTY TO SAFE MOVING CASUALTY TO SAFE AREA FOR TREATMENTAREA FOR TREATMENT
• Low profile for casualty and yourself
• May need to request assistance
• Protection outweighs risk of aggravating injuries
• NEVER hesitate to move a casualty who is under fire.
• If casualty is not under fire, you may elect to delay movement if C-spine injury likely.
8
MECHANISM OF MECHANISM OF INJURYINJURY
• Determine how injury occurred– Burns– Ballistics– Falls– NBC– Blast
9
NUMBER OF PATIENTSNUMBER OF PATIENTS
• Consider Mass casualty situation
• Triage patients accordingly• Need for assistance or
additional supplies• Manage time, equipment, and
resources
10
ADDITIONAL HELPADDITIONAL HELP
• Direct self-aid/buddy aid
• Request of suppressive fire for movement of casualties
• Plan evacuation routes
11
C-SPINE STABILIZATION/ C-SPINE STABILIZATION/ OTHER EQUIPMENTOTHER EQUIPMENT
• Spineboard
• C-collar
• Factors or Limitations of NBC environment
• Other equipment:
– Airway adjuncts
– Oxygen– Extrication devices
12
ASSESSMENT AND INITIAL ASSESSMENT AND INITIAL MANAGEMENT OF THE MANAGEMENT OF THE
TRAUMA PATIENTTRAUMA PATIENT
13
BTLS PRIMARY BTLS PRIMARY SURVEYSURVEY
• Scene Size-up
• Initial Assessment
• Rapid Trauma Survey or Focused Exam
14
PURPOSES OF INITIAL PURPOSES OF INITIAL ASSESSMENTASSESSMENT
• Prioritize casualties
• Determine immediate life threatening conditions
• Information gathered used to make decisions concerning critical interventions and time of transport
• No secondary interventions implemented before completion of initial assessment
15
NO SECONDARY NO SECONDARY INTERVENTIONS WILL BE INTERVENTIONS WILL BE IMPLEMENTED BEFORE IMPLEMENTED BEFORE COMPLETION OF INITIAL COMPLETION OF INITIAL
ASSESSMENT EXCEPT FOR:ASSESSMENT EXCEPT FOR:
• Airway Obstruction• Cardiac Arrest
16
FORM GENERALFORM GENERAL IMPRESSIONIMPRESSION
• Observe position of casualty– posture
– accessibility
• Appearance of casualty• Begin to establish priorities of
care
17
ESTABLISH C-SPINE CONTROLESTABLISH C-SPINE CONTROL AT THIS TIMEAT THIS TIME
18
LEVELS OFLEVELS OF CONSCIOUSNESSCONSCIOUSNESS
A – ALERT AND ORIENTED
V – RESPONDS TO VERBAL STIMULI
P – RESPONDS TO PAIN
U – UNRESPONSIVE (NO COUGH OR GAG REFLEX)
19
ASSESS AIRWAYASSESS AIRWAY
If patient is unable to speak or is unconscious then evaluate further
20
OPENING THE OPENING THE AIRWAYAIRWAY
Modified Jaw Thrust
21
OBSTRUCTED AIRWAYOBSTRUCTED AIRWAY
• Attempt to ventilate; if unsuccessful
• Reposition and attempt to ventilate again
• Visualize observing for obvious obstruction
• Suction, if needed
22
OBSTRUCTED AIRWAYOBSTRUCTED AIRWAYcon’tcon’t
• Consider FBAO management• Consider Combi-tube• Consider Needle Cricothroidotomy
23
RATE AND QUALITY OF RATE AND QUALITY OF RESPIRATIONSRESPIRATIONS
• Absent - Ventilate twice and check pulse and do CPR if required. Then provide PPV at 12-15 resp/min with 15L/m of O2
• Rate<12/min - BVM at 12-15/min with 15L/m of O2
• Low Tidal Volume - BVM at 12-15/min with 15L/m of O2
24
RATE AND QUALITY OF RATE AND QUALITY OF RESPIRATIONSRESPIRATIONS
• Labored - Oxygen by non-rebreather at 15L/min
• Normal or Rapid - All trauma patients should receive oxygen
• Ventilation rate is 12-15/min instead of 10-12 IAW AHA due to the patient being without oxygen for a probable extended period of time. The increase in ventilation rate also allows for mask leak which can average up to 40%.
25
ACTIONS FOR SPECIFIC ACTIONS FOR SPECIFIC AIRWAY SOUNDSAIRWAY SOUNDS
• Snoring - Jaw Thrust• Gurgling - Suction• Stridor – consider Combi-tube• Silence - Follow steps in
assessing airway
26
Assess CirculationAssess Circulation
27
Assess CirculationAssess Circulation
• Palpate carotid and radial pulses; brachial in an infant
• Check CCT
• Check for major bleeding
28
RADIAL PULSERADIAL PULSE
• Present - Note rate and quality• Bradycardia - Consider spinal
shock; head injury• Tachycardia - Consider shock• Absent - Check carotid pulse;
note late shock (consider PASG)
29
CAROTID PULSECAROTID PULSE
• Present - Note rate and quality• Bradycardia (<60bpm) -
Consider spinal shock; head injury
• Tachycardia (>120bpm) - Consider shock
• Absent - CPR + BVM+O2, Defib with AED as appropriate
30
CHECK FOR MAJOR CHECK FOR MAJOR BLEEDINGBLEEDING
• Direct pressure and elevation
• Pressure dressing • Pressure points
• Tourniquet
• PASG
31
CPRCPR
• Combat situation CPR will be METT-T dependent
• If METT-T allows, you would begin CPR for the potentially expectant patient
32
EXPOSE WOUNDSEXPOSE WOUNDS
• Remove all equipment and clothing from area around wounds
• Identify any additional life-threatening injuries
33
DCAP-BLSDCAP-BLS
• Deformities• Contusions• Abrasions• Penetrations
• Burns• Lacerations• Swelling
34
DeformitiesDeformities
35
Contusions (bruises)Contusions (bruises)
36
AbrasionsAbrasions
37
Punctures/PenetrationsPunctures/Penetrations
38
BurnsBurns
39
LacerationsLacerations
40
SwellingSwelling
41
PALPATIONPALPATION
Touching or feeling for:Touching or feeling for:• TIC
• TRD-P
42
TICTIC
• Acronym used when palpating body parts of the body
• TIC– Tenderness– Instability– Crepitus
43
TRD-PTRD-P• Acronym used when palpating
the abdomen• TRD-P
– Tenderness– Rigidity– Distention– Pulsating Masses
44
Head Neck Chest Abdomen Pelvis Extremities Back
Quick “Head-To-Toe” Exam
RAPID TRAUMA SURVEYRAPID TRAUMA SURVEY
45
RAPID TRAUMA SURVEYRAPID TRAUMA SURVEY• BRIEF exam done to find all
life-threats• No splinting done except for
anatomically splinting casualty to a spineboard
• Only a few interventions are done on scene
46
INTERVENTIONS INTERVENTIONS PERFORMED AT SCENEPERFORMED AT SCENE
• Initial Airway Management• Assist Ventilations• Begin CPR if METT-T allows• Control of major external
bleeding
47
INTERVENTIONS INTERVENTIONS PERFORMED AT SCENE PERFORMED AT SCENE
• Seal sucking chest wounds• Stabilize flail chest• Decompress tension
pneumothorax• Stabilize impaled objects
48
HEADHEAD• DCAP-BLS
• Obvious hemorrhage
• Major facial injuries - consider other airway adjuncts
• TIC
49
NECKNECK• DCAP-BLS• Retraction at suprasternal notch• Tracheal deviation• Jugular Vein Distention• Use of accessory muscles• TIC• Cervical spine step-off
50
AUSCULTATE FOR AIR AUSCULTATE FOR AIR SOUNDS IN TRACHEASOUNDS IN TRACHEA
• Stridor
• Gurgling• Snoring
51
APPLY C-COLLAR AFTER APPLY C-COLLAR AFTER ASSESSING NECKASSESSING NECK
52
Chest: DCAP-BLS + TIC, paradoxical motion, Chest: DCAP-BLS + TIC, paradoxical motion, Symmetry, Breath Sounds Symmetry, Breath Sounds (Presence and (Presence and
Quality)Quality), and heart sounds , and heart sounds (baseline (baseline measurement)measurement)
53
Listen to both sides of the chest. Listen to both sides of the chest. Is air entry present? Is air entry present?
Absent?Absent? Equal on both sides?Equal on both sides?
Compare left side to right side.Compare left side to right side.
Mid-ClavicularMid-Clavicular Mid-AxillaryMid-Axillary
54
DIMINISHED OR ABSENT DIMINISHED OR ABSENT BREATH SOUNDSBREATH SOUNDS
• Percuss to check for hemothorax vs. pneumothorax
• Hypo-resonance = Hemothorax• Hyper-resonance =
Pneumothorax
55
PNEUMOTHORAX OR COLLAPSED LUNG
• Collection of air or gas in pleural spaces
• Open chest wounds that permit entrance of air
• May occur spontaneously without apparent cause
56
OPEN PNEUMOTHORAXOPEN PNEUMOTHORAX
57
TENSION PNEUMOTHORAX• Required as consideration by any or all of the
following– Decreased or absent breath sounds– Decreasing LOC– Absent radial pulse– Cyanosis– Jugular Vein Distention– Tracheal Deviation– Decreasing bag compliance
58
TENSION PNEUMOTHORAXTENSION PNEUMOTHORAX
59
INDICATIONS TO DECOMPRESS INDICATIONS TO DECOMPRESS TENSION PNEUMOTHORAXTENSION PNEUMOTHORAX
The presence of tension pneumothorax with decompensation as evidenced by more than one of the following:
–Respiratory distress and cyanosis
–Loss of radial pulse (late shock)
–Decreasing LOC
60
• DCAP - BLS• External blood loss• Impaled objects• Evisceration• Inspect posterior
abdomen for exit wounds/bruising
• Palpate for:– TRD-P
ABDOMENABDOMEN
61
PELVISPELVIS
• DCAP-BLS
• Priaprism
• Incontinence• TIC
• Symphysis Pubis
• Iliac Crests
62
EXTREMITIESEXTREMITIES• Examine lower then
upper extremities • DCAP-BLS• TIC• PMS in each
extremity
63
LOGROLL AND PLACE ON LOGROLL AND PLACE ON BACKBOARD UNLESS BACKBOARD UNLESS CONTRAINDICATEDCONTRAINDICATED
CONTRAINDICATIONS TO LOGROLL:• Pelvic Instability
• Bilateral Femur Fractures
A Scoop Litter is required with these injuriesA Scoop Litter is required with these injuries
64
BACKBACK
• Done DURING transfer to backboard
• DCAP - BLS• Rectal Bleeding• TIC
65
SAMPLE HISTORY• S – SIGNS/SYMPTOMS
• A – ALLERGIES
• M – MEDICATIONS
• P – PAST MEDICAL HISTORY
• L – LAST MEAL
• E – EVENTS PRIOR TO INJURY
66
OBTAIN BASELINE VITALS
• Pulse• Respirations• Blood Pressure• Pupils• CCT
67
Neurological Exam
Perform brief exam if patient has an altered mental status
• PERL
• Glasgow Coma Scale (GCS)
• Assess disability
68
TRANSPORT PATIENT TRANSPORT PATIENT OR MOVE PATIENT TO OR MOVE PATIENT TO
CASUALTY CASUALTY COLLECTION POINTCOLLECTION POINT
69