Assessment of the Trauma Patient

21 Pages·2004·0.89 MB·English

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10
C H A P T E R
Assessment of the
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Trauma Patient et
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Covers Lesson 3-3 and portions of Lesson 3-9 of the 1994 U.S. Department nt
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of Transportation’s EMT-Basic National Standard Curriculum e,
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Total Teaching m
DOT OBJECTIVES E
Time: 6 hours c.
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Page numbers in parentheses refer to pages in the textbook. on, I
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Knowledge and Attitude The total teaching time being duc
recommended is only a guide- E
1. Discuss the reasons for reconsideration concerning the mechanism n
line. Instructors should take into o
of injury. (pp. 233, 245) consideration such factors as: ears
2. State the reasons for performing a rapid trauma assessment. P
the pace at which students learn, y
(pp. 246–247) the size of the class, and breaks. 5 b
0
3. Recite examples and explain why patients should receive a rapid The actual time devoted to 20
trauma assessment. (pp. 246–247) teaching objectives is the re- ©
4. Describe the areas included in the rapid trauma assessment and sponsibility of the instructor.
discuss what should be evaluated. (pp. 246–253)
5. Differentiate when the rapid assessment may be altered in order to
provide patient care. (pp. 246–247, 253–254)
6. Discuss the reason for performing a focused history and physical
exam. (p. 232)
7. Recognize and respect the feelings that patients might experience
during assessment. (pp. 235, 237, 248, 253)
8. Discuss the components of the detailed physical exam. (pp. 254–255,
Resources Needed
258–261)
•Scored Chapter 9 quizzes
9. State the areas of the body that are evaluated during the detailed
•2 nonstudent volunteers to
physical exam. (p. 254)
serve as patients
10. Explain what additional care should be provided while performing
•2 EMTs to serve as teaching
the detailed physical exam. (pp. 254–255, 258–261) assistants
11. Distinguish between the detailed physical exam that is performed •At least 2 trauma jump kits
on a trauma patient and that of the medical patient. (p. 000) with BSI equipment and a
12. Explain the rationale for the feelings that these patients might be selection of airways
experiencing. (pp. 235, 237, 248, 253)
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Skills
1. Demonstrate the rapid trauma assessment that should be used to
treat a patient based on mechanism of injury.
2. Demonstrate the skills involved in performing the detailed physical
exam.
REVIEW
In the last lesson, “Vital Signs and SAMPLE History,” students learned
why and how to go about obtaining a patient’s vital signs—pulse; respira-
tion; skin color, temperature, and condition; pupils; and blood pressure.
They learned the importance of obtaining baseline vital signs as a stan-
dard against which a patient’s improvement or deterioration can be
gauged when vital signs are later reassessed and recorded. They also dis-
covered how to gain basic information about the patient’s present prob-
lem and prior history by taking a SAMPLE history.
Distribute the scored quizzes from the last class. Review each of the
al.
et questions on the quiz and clarify or address any concerns students may
er have about the answers.
m
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diti INTRODUCTION TO
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nth CHAPTER 10
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ar Chapter 10, “Assessment of the Trauma Patient,” is the third lesson in
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y Module 3 of the DOT curriculum. Thus far, students have covered two
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ge steps in the patient assessment process: scene size-up and initial assess-
mer ment. After the initial assessment, they will begin a focused history and
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c. physical exam. Students in the last lesson learned about parts of the fo-
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n, I cused history and physical exam—the vital signs and the SAMPLE history.
atio In this lesson, they will see how the focused history and physical exam
uc should be carried out for trauma patients. For these patients, the key to
d
n E providing what the patients need is focus—honing in on what is impor-
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ars tant to these patients and striking a balance between time for assessment
Pe and emergency care and the need for as rapid transport as possible.
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05 Evaluation Distribute copies of the Chapter 10 Objectives Checklist to students and
0
© 2 Handout 10-1 ask them to look it over while you briefly paraphrase the objectives in
Chapter 10 Objectives Checklist your own words.
LECTURE
Teaching Tip
You might wish to start the class
by demonstrating a complete The following suggested lecture outline is based on the 1994 Department
trauma assessment to give of Transportation’s EMT-Basic National Standard Curriculum. In some
students an idea of how the places, topics in that outline have been rearranged or expanded upon to
sequence of steps is carried out enhance student understanding. The page numbers in parentheses in the
in real time. outline refer to pages in the textbook. The parenthetical references in
dark, heavy type are to figures, scans, and tables in the textbook.
(cid:1)
ASSESSMENT OF THE TRAUMA PATIENT
✧
PowerPoint I. Reconsider Mechanism of Injury (pp. 232–233)
Presentation A. Significant mechanism of injury (Table 10-1, p. 232; Table 10-2,
Chapter 10, Slides 2–15 p. 233)
1. Ejection from vehicle
2. Death in same passenger compartment
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3. Falls of more than 15 feet or 3 times patient’s height
4. Rollover of vehicle Point to Emphasize
5. High-speed vehicle collision Stress that patients must be
6. Vehicle-pedestrian collision treated based on mechanism of
7. Motorcycle crash injury as well as assessment
8. Unresponsive or altered mental status findings.
9. Penetrations of the head, chest, or abdomen
10. Hidden injuries
Slides/Videos
a. Seat belts
Pulse,“Kinetics of Trauma,”
(1) If buckled, may have produced injuries.
Jan. 1996.
(2) If patients had seat belts on, it does not mean they do
not have injuries.
b. Airbags Slides/Videos
(1) May not be effective without seat belt. Pulse,“Air Bag Injuries,”
(2) Patient can hit wheel after deflation. Jan. 1996.
(3) Lift the deployed airbag and look at the steering wheel
for deformation.
(a) “Lift and look” under the bag after the patient has Reading Reference
been removed. Colwell, C. MD, et. al. “Detecting al.
(b) Any visible deformation of the steering wheel Mechanism of Injury,” et
Emergency Medical Services, er
should be regarded as an indicator of potentially m
May 2003, Vol. 32, No. 5. m
serious internal injury, and appropriate action Li
should be taken. on.
B. Infant and child considerations (p. 233) diti
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1. Falls > 10 feet h
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2. Bicycle collision eT
3. Vehicle in medium-speed collision are,
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C. Apply a cervical collar to any patient suspected of having injury to y
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the spine based on mechanism of injury, history, or signs and en
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symptoms. (pp. 236–241) (Scan 10-2, pp. 238–241) ✧ mer
II. For Patients with No Significant Mechanism of Injury; e.g., cut PowerPoint Ec.
A.fRinegcoerns(ipdepr. m23e3c–h2a3n7is)m ( Toaf binleju 1ry0.- 1(,p p. 2. 3233)3) ChapterP 1r0e, sSelindetsa t3i,o 3n8–42 on, In
B. Determine chief complaint. (p. 233) cati
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C. Perform focused history and physical exam of injuries based on the Ed
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components of the rapid assessment. The focused assessment is o
performed on the specific injury site. (pp. 234–236) (Scan 10-1, ears
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pp. 234–235) y
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D. Assess baseline vital signs. (p. 236) 05
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1. Use pulse oximeter per local protocols. © 2
E. Obtain SAMPLE history. (Fig. 10-1, p. 236) ✧
III. Perform Rapid Trauma Assessment on Patients with Significant PowerPoint
Mechanism of Injury to Determine Life-Threatening Injuries Presentation
In the responsive patient, symptoms should be sought before and Chapter 10, Slides 16–37
during the trauma assessment. (pp. 232, 236, 242–243) (Table 10-1,
p. 232; Table 10-3, p. 236) (Scan 10-3, pp. 242–243)
Point to Emphasize
A. Reconsider mechanism of injury. (Fig. 10-2, p. 245; Fig. 10-3, p. 246)
The rapid trauma assessment is
B. Continue spinal stabilization. (p. 246)
helpful in finding life-threatening
C. Consider ALS request. (p. 246)
injuries.
D. Reconsider transport decision. (p. 246)
E. Assess mental status. (p. 246)
F. Perform rapid assessment. As you inspect and palpate, look and feel
Teaching Tip
for the following examples of injuries or signs of injury
At first, don’t allow students to
(pp. 246–247) (Scan 10-1, p. 234–235)
use the short form “DCAP-
1. Deformities
BTLS.” Making them say what
2. Contusions each letter stands for helps to
3. Abrasions ingrain the terms in the students’
4. Punctures/penetrations memory.
5. Burns
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6. Tenderness
Slides/Videos 7. Lacerations
Pulse—Emergency Medical 8. Swelling
Update, “Prehospital G. Assess the head, inspect and palpate for injuries or signs of injury.
Assessment, Treatment, and (p. 247)
Transportation.” (Pulse Plus) 1. Deformities
July 2003. (AHVP #464–0703)
2. Contusions
3. Abrasions
4. Punctures/penetrations
Point of Interest
5. Burns
Patients with an epidural brain
6. Tenderness
injury may present initialy as un-
7. Lacerations
conscious, then become con-
8. Swelling
scious, and then go unconscious
9. Crepitation
again. Be alert!
H. Assess the neck, inspect and palpate for injuries or signs of injury.
(pp. 247–248)
1. Deformities
Point to Emphasize
2. Contusions
Assume a possible spinal cord
al. injury if indicated by the mecha- 3. Abrasions
er et nism of injury. 4. Punctures/penetrations
m 5. Burns
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on. 7. Lacerations
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are, 11. Stoma/tracheostomy
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y I. Apply cervical spinal immobilization collar (CSIC). May use
c
en Slides/Videos information from the head injury lesson at this time. (p. 248)
g
er “Issues in Spinal Care.” Laerdal (Scan 10-2, pp. 238–241)
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Eon, Inc. MAremdoicnakl ,C NoYr p1.0, 5O0n4e. Labriola Ct., J. A(p1sps.e. Ds2s4e t8fho–er2m 4c9iht)ieesst, inspect and palpate for injuries or signs of injury.
cati 2. Contusions
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ears 5. Burns
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© 2 8. Swelling
9. Paradoxical motion (Fig. 10-4, p. 248)
10. Crepitation
Teaching Tip 11. Breath sounds in the apices, midclavicular line, bilaterally and at
Have students listen to each the bases, midaxillary line, bilaterally (Scan 10-4, p. 249)
other’s lung sounds frequently. a. Present
b. Absent
c. Equal
K. Assess the abdomen, inspect and palpate for injuries or signs of
injury. (pp. 248–250)
1. Deformities
2. Contusions
3. Abrasions
Point to Emphasize
4. Punctures/penetrations
Late assessment of blunt abdom-
5. Burns
inal trauma is one of the leading
6. Tenderness
factors in the deaths of patients
7. Lacerations
with abdominal injuries.
8. Swelling
9. Firm
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10. Soft
11. Distended Point to Emphasize
L. Assess the pelvis, inspect and palpate for injuries or signs of injury. Do NOT let students rock the
(pp. 250–251) pelvis to check stability.
1. Deformities
2. Contusions
3. Abrasions
4. Punctures/penetrations
5. Burns
6. Tenderness
7. Lacerations
8. Swelling
9. If no pain is noted, gently compress the pelvis to determine
tenderness or motion.
M. Assess all four extremities, inspect and palpate injuries or signs of Teaching Tip
injury. (pp. 251–252) (Scan 10-5, pp. 250–252) Point out to students that they
1. Deformities should not be distracted by dra-
2. Contusions matic extremity injuries—these
3. Abrasions are rarely life threatening. al.
4. Punctures/penetrations et
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5. Burns m
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6. Tenderness Li
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8. Swelling diti
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9. Distal pulse h
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10. Sensation eT
11. Motor function are,
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N. Roll patient with spinal precautions and assess posterior body, y
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inspect and palpate, examining for injuries or signs of injury. en
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(pp. 252–253) er
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O. Assess baseline vital signs. (p. 253) Ec.
QP.. AP1essr.feoUsrsms eS AipnMutePlsrLevE eo nhxtiiisomtnoesrt yea.r n (pdpe .t2rr 5al3on)csaplo prtr.o (tpopco. l2.53–254) ✧PowerPoint cation, In
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IV. Detailed Physical Exam (pp. 254–261) (Table 10-4, p. 255; Presentation Ed
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Table 10-5, p. 255) (Scan 10-6, pp. 256–258) Chapter 10, Slides 58–74 o
A. Perform en route to hospital if time and patient conditions permit. ears
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(p. 254) y
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B. Patient and injury specific (e.g., cut finger would not require the Point of Interest 05
The detailed physical exam is sim- 0
detailed physical exam). (pp. 254–255) ilar to the old secondary survey. © 2
C. Perform a detailed physical examination on the patient to gather
additional information. (pp. 255–261)
1. As you inspect and palpate, look and/or feel for injuries or signs
of injury.
a. Deformities Teaching Tip
Remind students to talk to the pa-
b. Contusions
tient, explaining what is going on
c. Abrasions
as the exam is carried out. Doing
d. Punctures/penetrations
so will make the exam easier for
e. Burns
both patient and EMT-B.
f. Tenderness
g. Lacerations
h. Swelling
2. Assess the head, inspect and palpate for injuries or signs of Point to Emphasize
injury. (Fig. 10-5, p. 259) What is not exposed cannot be
a. Deformities evaluated. Students should ex-
pose patients appropriately, bear-
b. Contusions
ing in mind considerations of
c. Abrasions
privacy and potential heat loss.
d. Punctures/penetrations
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e. Burns
f. Tenderness
Teaching Tip
g. Lacerations
Remind students that they can
h. Swelling
easily practice these exams at
3. Assess the face, inspect and palpate for injuries or signs of
home on spouses, other family
members—even the family dog injury.
or cat! a. Deformities
b. Contusions
c. Abrasions
d. Punctures/penetrations
e. Burns
f. Tenderness
g. Lacerations
h. Swelling
4. Assess the ears, inspect and palpate for injuries or signs of
injury.
a. Deformities
b. Contusions
al. c. Abrasions
et d. Punctures/penetrations
er
m e. Burns
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on. g. Lacerations
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eT Teaching Tip 5. Assess the eyes, inspect and palpate for injuries or signs of
are, Remind the student that the dis- injury.
y C patch information and chief a. Deformities
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en complaint may not match the b. Contusions
erg findings of the detailed assess- c. Abrasions
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Ec. tmhoenrot.u Tghhe d EeMtaTil emd uasstsedsos ma ent d. Punctures/penetrations
on, In in order not to miss any prob- ef.. BTeunrndserness
cati lems/injuries. g. Lacerations
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ears j. Unequal pupils
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05 l. Blood in anterior chamber (Fig. 10-7, p. 260) (p. 259)
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© 2 Point to Emphasize 6. Assess the nose, inspect and palpate for injuries or signs of
While doing the detailed assess- injury.
ment the EMT should pay atten- a. Deformities
tion to level of consciousness b. Contusions
and breathing in case the patient c. Abrasions
status changes.
d. Punctures/penetrations
e. Burns
f. Tenderness
g. Lacerations
h. Swelling
i. Drainage
j. Bleeding
Point to Emphasize 7. Assess the mouth, inspect and palpate for injuries or signs
Drive home to students the need of injury.
to be alert to potential airway a. Deformities
obstructions when assessing the b. Contusions
nose and mouth. c. Abrasions
d. Punctures/penetrations
e. Burns
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f. Tenderness
g. Lacerations
h. Swelling
i. Teeth
j. Obstructions
k. Swollen or lacerated tongue
l. Odors
m. Discoloration
8. Assess the neck, inspect and palpate for injuries or signs
of injury.
a. Deformities
b. Contusions
c. Abrasions
d. Punctures/penetrations
e. Burns
f. Tenderness
g. Lacerations
h. Swelling
i. Jugular vein distention al.
j. Crepitation et
er
9. Assess the chest, inspect and palpate for injuries or signs of Reading/Reference m
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injury. De Lorenzo, R. “Sneezes, Li
a. Deformities Wheezes, and Breezes— on.
b. Contusions Listening to the Chest,” JEMS, diti
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c. Abrasions Oct. 1995. h
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d. Punctures/penetrations eT
e. Burns are,
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and the bases, midaxillary line, bilaterally. cati
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(1) Present Ed
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(3) Equal ears
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10. Assess the abdomen, inspect and palpate for injuries or signs of y
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injury. 05
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a. Deformities © 2
b. Contusions
c. Abrasions
d. Punctures/penetrations
e. Burns
f. Tenderness
g. Lacerations
h. Swelling
i. Firm
j. Soft
k. Distended
11. Assess the pelvis, inspect and palpate for injuries or signs
of injury.
a. Deformities
b. Contusions
c. Abrasions
d. Punctures/penetrations
e. Burns
f. Tenderness
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g. Lacerations
h. Swelling
i. If the patient does not complain of pain or is unresponsive,
gently flex and compress the pelvis to determine stability.
12. Assess all four extremities, inspect and palpate for injuries or
signs of injury.
a. Deformities
b. Contusions
c. Abrasions
d. Punctures/penetrations
e. Burns
f. Tenderness
g. Lacerations
h. Swelling
i. Distal pulse
j. Sensation
k. Motor function
13. Roll with spinal precautions and assess posterior aspect of body,
al. inspect and palpate for injuries or signs of injury.
et a. Deformities
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diti e. Burns
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y Presentation V. Reassess Baseline Vital Signs (p. 260)
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c. REVIEW QUESTIONS
n
n, I Workbook
o Chapter 10Activities
ati Check on how well students can apply what they have learned by dis-
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du cussing the Review questions on page 267.
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arso Active Learning Q1: Explain why it is important to reconsider the mechanism of injury at
e the beginning of the focused history and physical examination of a
P Manual
by Chapter 10 trauma patient.
5
0 A1: When you first arrive at the scene and must take in so much infor-
0
2
© mation at once, it is easy to miss things.
Companion
Website Q2: Explain how the focused history and physical examination of a
Send students to trauma patient with a significant mechanism of injury differs from
http://www.prenhall.com/limmer. that for a trauma patient with no significant mechanism of injury.
A2: For the patient without a significant mechanism of injury, it is not
necessary to perform a rapid trauma assessment. Instead, you can
focus your assessment just on the areas that the patient tells you are
painful or that you suspect may be injured. Baseline vital signs and
a SAMPLE history must be obtained on all patients. (Table 10-1,
p. 232)
Q3: Name the signs and symptoms for which the letters DCAP-BTLS
stand.
Student CD A3: Deformities Burns
Chapter 10 Contusions Tenderness
Abrasions Lacerations
Punctures/penetrations Swelling (p. 000)
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Q4: List the steps of the rapid trauma assessment and describe the kind
Online Test
of patient for whom the rapid trauma assessment is appropriate.
Preparation
A4: The steps are: head, neck, chest, abdomen, pelvis, extremities, and
Send your students to
posterior. A patient with a significant mechanism of injury needs a
http://www.prenhall.com/
rapid trauma assessment.
EMTAchieve.
Q5: What are the additional areas that you assess in the detailed physical
exam that you did not evaluate in the rapid trauma assessment?
A5: The scalp and cranium, face, ears, nose, and mouth.
Q6: List the areas covered in the detailed physical exam. What do you
look and feel for in each of these areas?
A6: Refer to pp. 251–261 and to Table 10-5 on p. 255 of the textbook.
[Note: Application questions are covered in the Practice Scenarios and
Running a Call later in this lesson.]
STREET SCENES al.
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Ask a student to volunteer to read aloud to the class the case study on
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page 268 of the textbook. Discuss answers to questions at appropriate n. Li
points within the scenario. o
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Q1: What is the priority of this patient? nt
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A1: The patient is suffering from multi-trauma. The ABCs are the first e, T
priority, while protecting the cervical spine. The first treatment prior- ar
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ity is securing the airway and assuring adequate respirations y
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(breathing). Due to facial injuries, the EMT-Bs must make sure that e
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mucous, blood, and/or teeth are not causing airway obstructions. mer
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After applying a cervical collar and placing the patient on a back- c.
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board, the EMT-Bs should suction as needed and, if necessary, turn n, I
the patient on his side to allow for drainage. Next, the EMT-Bs should atio
apply occlusive dressing over the stab wound. They should also pro- uc
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vide the patient with high-concentration oxygen and, if necessary, n E
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assist ventilation. (Note to Instructor: Stress to students that in this ars
scenario the EMT-Bs should remain alert to the possibility of tension Pe
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pneumothorax throughout the call. Explain this condition and/or b
5
refer students to the appropriate information and diagrams in 00
2
Chapter 27, “Soft-Tissue Injuries.”) ©
Q2: What should be done next?
A2: The patient requires rapid transport to a trauma center. After man-
aging the airway and breathing, and controlling any external
bleeding, the EMT-Bs should package the patient for immediate
transport.
Q3: When should vital signs be taken?
A3: A baseline set of vital signs should be taken as soon as possible.
Because the patient has a serious mechanism of injury, vitals should
be retaken every 5–10 minutes.
Q4: What should you do next?
A4: The patient seems to have developed difficulty breathing until the
EMT-B lifts part of the occlusive dressing and allows some air to
escape. Point out that this is suggestive of tension pneumothorax (see
Question 1). In this situation, a corner of the occlusive dressing
should be raised, which provides some relief. If this is successful, the
EMT-Bs should then continue to monitor the patient. They should
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remain prepared to assist ventilations and, if time allows, consider
requesting ALS intercept. (Note to Instructor: Intercept, however,
should not delay transport time significantly.)
Q5: What should be done for the detailed assessment if there is time be-
fore reaching the trauma center?
A5: The ABCs remain the first priority. However, as time and patient con-
ditions permit, the detailed assessment should include the head-to-toe
survey suggested on pages 000–000 of the textbook. In the case of this
scenario, you might stress these points: 1. If the EMT-Bs did not check
the posterior when they backboarded the patient, they should do so
now. 2. They should also pay special attention to facial injuries and
parts of the body that made contact with the ground when the
patient was first thrown down.
Q6: How will DCAP-BTLS help with the assessment?
A6: Deformities—injuries from being thrown on the ground or beaten;
Contusions—facial cuts/wounds; Abrasions from mugging or from
falling; Penetrations—the EMT-Bs would have already identified the
al. penetrating knife wound; Burns—unlikely; Tenderness—areas hit or
et impacted with great force (from mugging or from hitting the
er
m ground); Lacerations—may be evident from causes already men-
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Li tioned; Swelling—should be anticipated to any part of the body that
on. received an injury due to great force.
diti
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eT PRACTICE SCENARIOS
e,
ar
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y Arrange for two vacant classrooms or other private areas to serve as prac-
c
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e tice scenario stations. Then set up the following two scenarios:
g
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Ec. SCENARIO STATION ONE
n
n, I Set up the station with one nonstudent acting the part of a trauma patient
atio with a nonsignificant mechanism of injury. Before class, brief the patient
uc on his or her role, explaining that he or she is an adult patient who has
d
n E accidentally cut his or her finger at home with a kitchen knife. When the
o
ars EMT-B students arrive, the cut is bleeding profusely. You may moulage
Pe the patient if desired. Assign a volunteer EMT to the station as a teaching
y
b assistant.
5
0
© 20 (cid:1) SCENARIO STATION TWO
Set up the station with one nonstudent acting the part of a trauma patient
with a significant mechanism of injury. Before class, brief the patient on
his or her role, explaining that he or she is a teenager who has been shot
at school by a member of a rival gang. When the EMT-B students arrive,
the patient is lying in a pool of blood, but is able to speak. You may
moulage the patient if desired. Assign a volunteer EMT to the station as a
teaching assistant.
Divide the class into groups of two. If you have an odd number of stu-
dents, one team of three is acceptable. Explain that you have set up two
practice scenarios, one dealing with a patient with minor trauma and one
dealing with a patient with major trauma. Instruct each team to visit each
station and act appropriately on what it finds there. Point out that, al-
though the emphasis of the scenarios is on the focused history and physi-
cal exam, students should also utilize other appropriate information and
skills they have learned to date. However, they should not worry about
administering patient care. Inform them that at both stations there will be
an EMT who will observe the teams’ performance and provide feedback.
184 Module 3 • Patient Assessment