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- Inspect from head to toe for both trauma signs (DCAP-BTLS) and medical signs.
- Only perform the detailed exam there are no life-threatening conditions to be managed.
- You are not required to perform a detailed physical exam for every patient.
- Head: look for DCAP-BTLS to the skull and scalp.
- Ear
- Look inside the ear for CSF leakage, which indicates skull fracture.
- Allow any CSF to leak onto a loose dressing.
- CSF contains glucose, which can be detected by a glucometer.
- Look behind the ear (mastoid process). Black-and-blue discoloration (Ecchymosis) is called the Battle's sign, which is a late sign of head injury.
- Face
- Look for facial deformities / bleeding that may obstruct the airway.
- Burns to the face may indicate burns to the upper airway, which may cause swelling and constriction of the airway.
- Eyes
- Test for consensual reflex (normally, both pupils should respond when light is shined onto one pupil).
- Pupil response to light should be fast. Sluggish response indicates poor perfusion to the brain, high CO2 levels and brain injuries.
- Unequal pupils indicate head injury or stroke.
- Fixed and dilated pupils indicate possible cardiac arrest or severe head injury.
- Pinpoint pupils indicate narcotic influence.
- Check for visual acuity: "how many fingers am I holding up?"
- Check for conjugate movement: eyes should move smoothly and together. Jerky eye movements (nystagmus) indicates drug influence or CNS problems. Dysconjugate gaze indicates injuries to eye or nerve.
- Nose
- Look for deformities and burns that may indicate airway compromise.
- Leakage of CSF indicates skull fracture.
- Nasal flaring is a sign of inadequate breathing.
- Mouth
- Inspect for and manage injuries that may cause airway compromise.
- Bite injuries to tongue indicate possible seizure / epilepsy.
- Cyanosis to the oral membranes indicate hypoxia.
- Pale tongue may indicate shock.
- Burns / white areas indicate ingestion of caustic substances / poison.
- Alcoholic odors indicate alcohol intoxication.
- Fruity odors indicate a diabetic emergency.
- Unusual / chemical odors may indicate substance abuse.
- Neck
- Open wounds need to be covered with occlusive dressing to prevent air being sucked into vein.
- JVD indicates heart failure or compression due to tension pneumothorax.
- Tracheal deviation is a late sign for tension pneumothorax.
- Crepitations are caused by air under the skin called subcutaneous emphysema. They indicate respiratory trauma.
- Use of neck muscles to breath and tracheal tugging indicate respiratory distress.
- Chest
- Check for retractions, which indicate respiratory distress.
- Look and feel for equal chest rise. Unequal chest rise indicates injuries to one side such as pneumothorax and flail segments.
- Paradoxical movement and flail segments need stabilization.
- Auscultate for breath sounds.
- Wheezing indicates constriction of bronchioles. When wheezing is isolated to a specific area, it indicates a localized infection or obstruction.
- Stridor: upper airway obstruction.
- Crackles / rales are caused by fluids in the lung.
- Rhonchi (snoring sound upon auscultation) are caused by mucus in the airway.
- Coughing blood indicates lung injury. Yellow or green sputum indicates infection.
- Abdomen
- Patients in a defensive position complaining of abdominal pain indicates peritoneum irritation.
- Patients who can freely move about and complains of abdominal pain indicates bowel obstruction.
- Tenderness, rigidity, discoloration are signs of internal bleeding.
- Guarding, rigidity, and shallow breaths are signs of peritonitis.
- Pulsating mass in the abdomen indicates weakened abdominal aorta.
- Cover eviscerations with most sterile dressing and seal it with an occlusive dressing.
- Pelvis
- Assess for pelvic stability. Pelvic fractures can cause significant internal bleeding.
- Priapism (persistent erection) is a sign of spinal cord injury.
- Note any bleeding and loss of bladder control.
- Lower extremities
- PMS: presence dorsalis pedis pulse, both feet can push down with equal strength, can feel both touch and pain (pinch) to the foot and also locate which side the was touched/pinched.
- Hemiplegia: paralysis to one side. This is a sign for stroke.
- Paraplegia: paralysis involving both legs only.
- Quadriplegia: paralysis involving both arms and both legs.
- Upper extremities
- PMS: presence radial pulse, both hands can wiggle their fingers and grip with equal strength, can feel and locate both touch and pain.
- Unequal grips is a sign for stroke.
- Back
- Just like everything else, assess for trauma signs.
- Muscle spasms around the vertebrae is a sign of spinal injury.
- Maintain an in-line stabilization.
- Reassess Vital Signs
- Every 5 minutes for unstable patients.
- Every 15 minutes for stable patients.
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