3-3 Focused History and Physical Exam - Trauma Patients

Unstable trauma patient

1. Notice significant MOI, multiple injuries or altered mental status.
2. Continue holding C-spine.
3. Consider ALS intercept.
4. Reconsider transport decision.
5. Reassess mental status.
6. Rapid trauma assessment.
7. Baseline vitals.
8. SAMPLE history.
9. Transport.
10. Detailed physical exam in the ambulance enroute to the hospital.
11. Ongoing assessment.

Stable trauma patient

1. Notice the absence of significant MOI, no multiple injuries, no altered mental status.
2. Focused trauma assessment.
3. Baseline vitals.
4. SAMPLE history.
5. Detailed physical exam on the scene.
6. Transport.
7. Ongoing assessment

Reassess mental status

• Ask for name, time, and location to probe mental status.
• Treat diabetic emergencies (hypoglycemia) by measure blood glucose and then administering glucose.
• Treat inadequate breathing and hypoxia-induced altered mental status with oxygen and PPV.
• Assess for the Glasgow coma scale. In a range of 3-15, 8 or is severe.

• Glasgow coma scale
  Eye opening
  Spontaneous	4
  To verbal stimulus	3
  To painful stimulus	2
  No response	1
  Verbal response
  Orientated talk	5
  Disorientated talk	4
  Inappropriate words	3
  Incomprehensible sounds	2
  No response	1
  Motor response
  Obeys verbal commands	6
  Localizes pain	5
  Withdraws from pain (flexion)	4
  Flexion (decorticate)	3
  Extension (decerebrate)	2
  No response	1

Rapid trauma assessment

• In 2 - 2.5 minutes, rapidly assess from head to toe for DCAP-BTLS: Deformities, Contusions, Abrasions, Punctures/penetrations, Burns, Tenderness, Lacerations, Swelling. Always call for ALS intercept for critical findings.
• Head and Face
  • Scalp, skull, ears, pupils, nose, mouth.
  • Look for airway compromises.
  • Also look for signs of brain damage such as CSF leakage from the ear and nose.
  • Look for signs of brain herniation (altered mental status, flexion, extension, fixed / unequal pupils). Treat with hyperventilation (20 bpm).
• Neck
  • Open wounds on the neck demands occlusive dressing to prevent air from being sucked into a large vein.
  • Jugular vein distention is a sign of heart failure and/or lung injury.
  • Tracheal deviation: tension pneumothorax (lung injury with pressure build-up)
  • Tracheal tugging: airway obstruction.
  • Subcutaneous emphysema: bulge in skin from air getting trapped inside.
  • Apply a cervical collar.
• Chest
  • Open wounds on the chest demand occlusive dressing taped on three sides. Also called a sucking wound because of air sucking into to the chest and can cause the lung to collapse. Occlusive dressing taped on three sides to allow air to escape on exhalation.
  • Look for paradoxical movement (when a portion of the chest moves inward during inhalation) such as flail segments (from broken ribs) and stabilize them.
  • Absence of or inadequate breath sounds or chest movement: begin PPV and O2 administration.
  • Muscle retractions and asymmetrical chest movement. Auscultate for chest sounds.
• Abdomen
  • Pain, tenderness (react to palpation), rigidity (tensed abdominal muscles) indicate internal bleeding into the abdominal cavity. The patient is likely to go into shock. Monitor ABCs and intervene appropriately.
  • The heel jar test probes for internal injury by striking the patient's heel with a fist. If the patient feels pain in the abdomen, then it's a sign of internal injury.
  • Evisceration: apply sterile dressing and cover it with an occlusive dressing. Monitor ABCs and intervene appropriately.
• Pelvis: Pain, tenderness, instability and deformations indicate a broken pelvis.
• Lower extremities
  • inspect and palpate each. Assess PMS (pedal pulses, motor and sensory function).
  • Control active bleeding.
  • Pain, swelling, discoloration, and deformity indicate a femur fracture.
• Upper extremities
  • Inspect and palpate each. Assess PMS (radial pulses, motor and sensory function).
  • Control active bleeding.
  • Deformations indicate bone fractures.
• Back: turn the patient on his or her side and inspect and palpate the posterior body.
  • Open wounds in the posterior thorax demands occlusive dressing. This is the same as a "sucking wound" on the chest. Occlusive dressing taped on three sides to allow air to escape during exhalation.
  • Manage active bleeding.
  • Note for any spinal deformations.
  • Maintain in-line stabilization until patient is secured onto a backboard.

Focused trauma assessment

• Assess the injured site for DCAP-BTLS
• Injuries to the extremities without active or internal bleeding are seldom life-threatening.
• Perform necessary interventions such as splinting and immobilization of a joint.
• Check PMS before and after interventions to the extremity.
• If your index of suspicion rises during the focused trauma assessment, proceed to perform a head-to-toe rapid trauma assessment.