Focused History and Physical Exam- Trauma Pt.

Focused History and Physical Exam- Trauma Pt.

• MOI Guides physical exam

• Significant MOI• Rapid Trauma Assess

• Not Significant MOI• Focused Trauma Assessment

Significant MOIs

• Significant MOI• Ejection from a vehicle • Death in same passenger compartment• Fall greater than 20 ft (adult)• Roll-over vehicle• High-speed vehicle collision• Vehicle-pedestrian collision • Motorcycle crash• Unresponsive/AMS pt• Penetrations

• Head• Chest• Abdomen

Special Populations & MOI

• Infants/Peds• Significant MOI

• Falls greater than 10 ft.• Bicycle Collision• Vehicle in medium speed collision• Compensate well and then crash

• Elderly • Tend to compensate poorly • Decompensate FAST• Prescribed meds could interfere with assessment• Lesser MOI = Greater injury

Thoracic Stab Wound

Abdominal Stab Wound

Hidden Injuries

• Safety devices cant prevent everything

• If they had one on it does not exclude all injury

• Deceleration = Sheering Forces

• Loose lap belt• Compression of abd

• Shoulder belt minus lap belt• Neck injury

• Airbag deployment• Pt could still have hit the

wheel• “Lift and Look”

• Inspect steering wheel• Steering Wheel

deformity= SERIOUS injury

Pneumothorax

Hemothorax

Rapid Trauma Assessment

• What• Rapid head-to-toe assessment of pt by palpation• DCAP-BTLS

• Who• ALL pt with significant MOI

• Why• Assess for life threatening injuries

• How• Responsive= Seek symptoms before, during, after assessment• Unresponsive= Rely on signs before, during, after assessment

DCAP-BTLS

• Deformity • “Structural distortion/bend that

alters the normal appearance

of the body/body part”• Broken bones, soft tissue

swelling, etc.• Crepitus

• Grating/crunching sound as one bone fragment rubs against another

• Subcutaneous Emphysema• Air beneath the skin

Subcutaneous Subcutaneous Emphysema Emphysema

Whats this from?

DCAP-BTLS

• Contusions• “Injury to body part

without break in the skin” • Blunt force trauma

compresses underlying vessels

• Vessels become “leaky” and rupture

• Hematoma• Blood collection under

the skin

DCAP-BTLS

• Abrasions• “Scraping of the surface

of the skin/mucous membrane”

• Superficial capillaries break = Oozing

• Painful Blood

DCAP-BTLS

• Punctures/Penetrations• “Sharp instrument driven

through the outer layer of skin”

• VERY deceiving• Small puncture can go VERY

deep

DCAP-BTLS

• Burns• Sources

• Thermal – Electrical - Chemical• Types

• Superficial (1st degree)• Upper level of the skin (epidermis)• Redness and pain

• Sunburn• Partial Thickness (2nd degree)

• Upper and lower level of skin (Epidermis/Dermis)• Blistering w/ w/o redness of skin• VERY painful

• Full Thickness (3rd degree)• Extension through upper and lower layers of skin• Black/charred red, Yellow/Brown, Dark red, White/Translucent • Little pain, pain from associated 1st and 2nd degree burns

DCAP-BTLS

• Tenderness• “Pain elicited upon

palpation”

DCAP-BTLS

• Lacerations• “Tearing of the skin or

surface tissues”• Blunt tearing forces

• Increases collateral tissue damage

• Sharp objects• Minimize collateral

tissue damage

Sharp Object

Blunt Trauma

DCAP-BTLS

• Swelling (edema)• “Abnormal

enlargement of a body part/organ”

• Caused by increased volume of fluid

• In Blood vessels• Between cells

Pitting Edema

Rapid Trauma Assessment

• Head-to-to Exam• VISUALIZE and PALPATE EVERYTHING!!!

• Apply DCAP-BTLS

• SAMPLE HX• BASELINE VITALS

Rapid Trauma AssessmentHead

• Inspect/Palpate• DCAP-BTLS • Crepitation

• Battle’s Signs• Bruising immediately behind the ears• Suggestive of basal skull fracture

• Raccoon eyes• Bilateral black eyes• Suggestive of a basal skull fracture

• Halo test• If fluid is present draining out of nose/ears• Collect small sample with gauze pad• If CSF is present in the blood it will separate out• A halo is created

• Blood in the center• CSF in the periphery

Raccoon EyesBattle’s Signs

Rapid Trauma AssessmentNeck

• Inspect/Palpate• DCAP-BTLS • Crepitation• C-Spine “Step Off”

• Jugular Vein Distention • Indicates increased venous

pressure • Assessed at 45O

• Trachea• Midline • Deviation…

• Subcutaneous Emphysema • APPLY C-COLLAR!!!!!!!!!!!!!!!

JVD

Rapid Trauma AssessmentChest

• Inspect/Palpate• DCAP-BTLS • Crepitation

• Paradoxical Motion• Movement of part of the chest wall that is

opposite that of the rest of the chest• Flail Segment

• Breath sounds• Mid clavicular lines bilaterally• Mid axillary lines bilaterally

• Present or Absent• Equal or diminished

Rapid Trauma AssessmentAbdomen

• Inspect/Palpate• DCAP-BTLS • Crepitation

• Rebound Tenderness• Distention • Resistance

• Firm• Tender• Soft

Rapid Trauma AssessmentPelvis

• Inspect/Palpate• DCAP-BTLS • Crepitation

• Stability • If no pain • Gently compress pelvis

posteriorly and medially

• Priapism • Painful erection of the penis indicative of spinal injury • Loss of sympathetic tone

Rapid Trauma AssessmentLower Extremities

• Inspect/Palpate• DCAP-BTLS • Crepitation

• Work bilaterally at the same time• Makes comparison easy• 1 L of blood from femur Fx

• ONLY 1-2 Cm swelling• Start at top and work your way down• Palpate entirely around the part• Assess for PMS!!!!!!!!

• Pulse• Motor• Sensation

Rapid Trauma AssessmentUpper Extremities

• Inspect/Palpate• DCAP-BTLS • Crepitation

• Work bilaterally at the same time• Start at clavicles/shoulder and work down • Palpate entirely around the part

• Makes comparison easy

• Assess for PMS!!!!!!!!• Pulse• Motor• Sensation

Rapid Trauma AssessmentPosterior

• Use C-Spine Control!!!!• Log-roll pt to lateral position

and inspect for• DCAP-BTLS • Crepitation• Vertebral “step offs”

• !!!DON’T FORGET THE PT HAS A BACK!!!!

Focused Trauma Assessment

• What• Focused assessment of injured area• Lead by the MOI

• Who• Pt with non significant MOI

• Why• Assess specific area of injury

• How• Assess for DCAP-BTLS at site of injury• Assess baseline vitals• Obtain SAMPLE history