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International Trauma

Life Support
for Prehospital Care Providers
Sixth Edition

Patricia M. Hicks, MS, NREMTP


Roy Alson, PhD, MD, FACEP
Donna Hastings, EMT-P
John Emory Campbell, MD, FACEP
and Alabama Chapter,
American College of Emergency Physicians

Chapter 2
Assessment and Initial Management of the Trauma Patient
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ
Assessment
and Initial Management
of the Trauma Patient Courtesy of ITLS Ontario

Campbell, International Trauma Life Support, 6th Ed.


2008 Pearson Education, Inc., Upper Saddle River, NJ
Overview
Steps of ITLS Patient Assessment
ITLS Primary Survey
ITLS Secondary Survey
ITLS Ongoing Exam

Initial Assessment related to


Rapid Trauma Survey or Focused Exam
Initial Assessment interruptions

Critical conditions and critical interventions

Patient Assessment - 3
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ
ITLS Patient Assessment
ITLS Primary Survey
Scene Size-up
Initial Assessment
Rapid Trauma Survey
or Focused Exam

ITLS Secondary Survey


ITLS Ongoing Exam

Patient Assessment - 4
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ
ITLS Primary Survey
ITLS Primary Survey
Scene Size-up
Initial Assessment
Rapid Trauma Survey
or Focused Exam

Patient Assessment - 5
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ
Scene Size-up

Patient Assessment - 6
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ
Scene Size-up

Patient Assessment - 7
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ
Initial Assessment

Patient Assessment - 8
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ
ITLS Primary Survey
Initial Assessment
General impression
Initial level of consciousness
Manual stabilization of cervical spine
ABCs

Prioritizes patient
Determines existence of immediately
life-threatening conditions

Patient Assessment - 9
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ
ITLS Primary Survey
Less than 2 minutes
Initial Assessment and Rapid Trauma Survey
Delegate any intervention.
Interrupt survey only for:

Scene danger
Airway obstruction
Cardiac arrest
Patient Assessment - 10
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ
ITLS Primary Survey
General impression
Approximate age, sex, weight
General appearance
Position of patient body and surroundings
Patient activity
Obvious major injuries or bleeding

Triage patients rapidly, if necessary.

Patient Assessment - 11
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ
ITLS Primary Survey

Patient Assessment - 12
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ
ITLS Primary Survey
Airway: look, listen, feel
Direct: simple positioning and suctioning

If not adequate, not quickly correctable


Interrupt: advanced airway techniques

Patient Assessment - 13
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ
ITLS Primary Survey
Breathing: look, listen, feel
Direct: high-flow oxygen

If not adequate
Direct: assisted ventilation

Patient Assessment - 14
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ
Breathing Rates
Normal Abnormal
Adult 1020 <10 and >24

Child 1530 <15 and >35

Infant 2550 <25 and >60

Patient Assessment - 15
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ
ITLS Primary Survey
Circulation: peripheral pulse
No peripheral, check carotid
Too fast, too slow, quality
Interrupt: cardiac arrest

Skin
Color, temperature, condition

Major bleeding scan


Direct: bleeding control

Patient Assessment - 16
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ
MOI Decision
Dangerous generalized
or unconscious
Rapid Trauma Survey

Dangerous focused
Focused Exam

Not significant
Initial Assessment normal
Focused Exam

Patient Assessment - 17
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ
Priority Patient
Dangerous MOI High-risk group
Altered mental status
History Difficulty breathing
Loss of consciousness
Abnormal perfusion
Difficulty breathing
Abnormal Initial Assessment
Severe pain
in head, neck, torso

Patient Assessment - 18
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ
Rapid Trauma Survey

Patient Assessment - 19
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ
Rapid Trauma Survey

Inspect Head and Neck


Major Facial Injuries, Bruising, Swelling,
Penetrations, Subcutaneous Emphysema
Neck Vein Distention? Tracheal Deviation?

Patient Assessment - 20
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ
Rapid Trauma Survey

Inspect Chest
Asymmetry, Contusion, Penetrations,
Paradoxical Motion, Instability, Crepitation
Breath Sounds
Present? Equal?
(If unequal: Percussion)
Heart Tones

Patient Assessment - 21
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ
Rapid Trauma Survey

Abdomen
Bruising, Penetration/Evisceration, Tenderness,
Rigidity, Distention
Pelvis
Tenderness, Instability, Crepitation

Patient Assessment - 22
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ
Rapid Trauma Survey

Lower/Upper Extremities
Swelling, Deformity, Instability, Motor, Sensory
Place Patient on Backboard
Posterior
Penetrations, Deformity, Presacral Edema

Patient Assessment - 23
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ
Rapid Trauma Survey

If critical situation,
transfer to ambulance to complete exam.

Patient Assessment - 24
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ
Rapid Trauma Survey

Baseline Vital Signs


Measured Pulse, Respirations, Blood Pressure
Pupils
Size? Reactive? Equal?
(If Altered Mental Status:)
Glasgow Coma Scale Score
Eyes, Voice, Motor, Orientation, Emotional State

Patient Assessment - 25
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ
Glasgow Coma Scale

*Decorticate posturing to pain


**Decerebrate posturing to pain

Patient Assessment - 26
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ
Brief Targeted History
S Symptoms
A Allergies
M Medications
P Past medical history
L Last oral intake
E Events preceding incident

Patient Assessment - 27
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ
Load-and-Go Situations
Initial Assessment Shock potential
Altered mental status Abnormal chest exam
Abnormal respiration Tender, distended
Abnormal circulation abdomen
Pelvic instability
Bilateral femur fractures

Significant MOI and/or poor general health

Patient Assessment - 28
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ
When in doubttransport early!

Patient Assessment - 29
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ
Critical Interventions
On-scene procedures
Manage airway Seal sucking chest
Assist ventilation Stabilize flail chest
Administer oxygen Decompress tension
pneumothorax
Begin CPR
Stabilize impaled
Control major
external bleeding Complete packaging

Patient Assessment - 30
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ
Initiate Transport
Procedures not on scene, not life-saving
Splinting, bandaging, IV line insertion
Endotracheal intubation, often

Contact medical direction


As early as possible
Estimated time of arrival (ETA)
Condition of patient
Special needs on arrival

Patient Assessment - 31
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ
ITLS Secondary Survey

Patient Assessment - 32
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ
ITLS Secondary Survey
More comprehensive exam
Evaluation for all injuries, not just life-threatening
Establishes baseline for treatment decisions

Performed
Critical patientsdone during transport
Short transportmay not have time
Non-critical patientsdone on scene

Patient Assessment - 33
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ
ITLS Secondary Survey
Initial Assessment
Repeat routinely

Vital signs
Repeat routinely
Monitoring

Detailed Exam
Head-to-toe
DCAP-BTLS

Patient Assessment - 34
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ
ITLS Secondary Survey
INITIAL ASSESSMENT
LOC
AVPU
Airway
Control Cervical Spine
Snoring, Gurgling, Stridor, Silence
Breathing
Present? Rate, Depth, Effort
Carotid/Radial Pulses
Present? Rate, Rhythm, Quality
Skin Color, Temperature, Moisture; Capillary Refill
Uncontrolled External Hemorrhage?
Patient Assessment - 35
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ
Detailed Exam: DCAP-BTLS

Deformities Burns
Contusions Tenderness
Abrasions Lacerations
Penetrations Swelling

Patient Assessment - 36
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ
ITLS Secondary Survey
DETAILED EXAM
Patient History
Complete SAMPLE History
Vital Signs
Measured Pulse, Respirations, Blood Pressure
SpO2, ECG, Blood Sugar, EtCO2
Glasgow Coma Scale Score
Eyes, Voice, Movement; Emotional State
Head
Pupils, Battles Sign, Raccoon Eyes, Drainage;
DCAP-BTLS

Patient Assessment - 37
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ
ITLS Secondary Survey
Neck
DCAP-BTLS; Neck Vein Distention? Tracheal Deviation?
Chest
Asymmetry; Paradoxical Motion; DCAP-BTLS;
Tenderness, Instability, Crepitation [TIC]
Breath Sounds
Present? Equal?
(If unequal: Percussion)
Heart Tones

Patient Assessment - 38
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ
ITLS Secondary Survey
Abdomen
DCAP-BTLS; Rigidity, Distention
Pelvis
DCAP-BTLS
Lower/Upper Extremities
DCAP-BTLS; TIC; PMS
Posterior
Examine only if not done in ITLS Primary Survey
DCAP-BTLS

Patient Assessment - 39
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ
ITLS Ongoing Exam
Change in condition
Patient
Interventions

Perform and record


Critical: every 5 minutes
Stable: every 15 minutes
Each time patient moved
With each intervention
If condition worsens
Patient Assessment - 40
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ
ITLS Ongoing Exam
Subjective Changes
How do you feel?
Reassess Mental Status
LOC, Pupils, GCS
Reassess ABCs
Patency, Vital Signs, Color, Skin Condition, Temperature,
JVD, Tracheal Deviation, Breath Sounds, Heart Tones
Reassess Abdomen
Development of Tenderness, Distention, Rigidity
Check Each Identified Injury
Change in Status, PMS
Check Interventions
Patency, Position, Flow Rate, Security
Patient Assessment - 41
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ
Summary
ITLS Patient Assessment
Key to trauma care
Not difficult, but time-critical
Rapid, orderly, thorough

Remain calm
Optimum speed by organization and teamwork

Patient Assessment - 42
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ
Discussion

Patient Assessment - 43
Campbell, International Trauma Life Support, 6th Ed.
2008 Pearson Education, Inc., Upper Saddle River, NJ

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