# trauma assessment question



## wlamoreemtb (Dec 10, 2008)

Hi im a medic student just finishing up my first semester. I have a question regarding trauma assessment mainly your initial assessment. When assessing breathing during your initial assessment do you auscultate breath sounds or just palpate for symmetry listen and count respirations? one of our instructors said that we had to auscultate in our initial assessment but the 3 or 4 other times we practiced we did that while reassessing. we are testing on this skill saturday and have our first semester written final on Monday. thanks for answers in advance


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## MSDeltaFlt (Dec 10, 2008)

http://www.nremt.org/EMTServices/exam_coord_man.asp?secID=1#ASkillSheets

The above link will offer practical check sheets on NR.  Do what they say do.


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## TomB (Dec 10, 2008)

Breathing
-Assess breathing (1 point)
-Assures adequate ventilation (1 point) 
-Initiates appropriate oxygen therapy (1 point)
-Manages any injury which may compromise breathing/ventilation (1 point)

I would argue that you can't adequately assess breathing and ventilation (and manage any injuries which may compromise breathing and ventilation) without assessing breath sounds. You also can't reassess something you haven't assessed in the first place. Ask yourself "What is the first thing the physician does when you roll in with a critically ill patient?" and you'll have your answer. Do what your instructors tell you to do for the class. When you're done jumping through hoops, do what's best for the patient and what works for you. Good luck!


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## traumateam1 (Dec 10, 2008)

TomB said:


> Breathing
> -Assess breathing (1 point)
> -Assures adequate ventilation (1 point)
> -Initiates appropriate oxygen therapy (1 point)
> ...



And if there is a massive bleed being hidden by clothing? Isn't assessing with a steth during the *initial* assessment a waste of some time?

If there is a reason to check breathing more detailed like SOB, cyanosis, unequal chest movement, than wouldn't you use a steth to assess LS, but during a initial trauma assessment than wouldn't using your hands to check rate/rhythm/quality work?

I'm not an EMT-P so this is just what *I've* been taught, so don't be to harsh on me ^_^.

Thanks!


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## MSDeltaFlt (Dec 10, 2008)

traumateam1 said:


> And if there is a massive bleed being hidden by clothing? Isn't assessing with a steth during the *initial* assessment a *waste of some time*?
> 
> If there is a reason to check breathing more detailed like SOB, cyanosis, unequal chest movement, than wouldn't you use a steth to assess LS, but during a initial trauma assessment than wouldn't using your hands to check rate/rhythm/quality work?
> 
> ...



No.  During your initial trauma assessment, you need to assure you have equal bilateral breath sounds.  Kinda hard to do that without a stethescope.  

Remember that your initial trauma assessment deals with your A-B-C'S.  What that means is assessing and treating life threatening conditions; i.e. a tension pneumothorax.  You do that before you move the pt.  The detailed assessments happen enroute.  

"To dart, or not to dart.  That is the question".  

Tracheal deviation is a late sign, as we all know.  So how do we tell?  Get out your stethescope and *listen to them* along with the history you get from observing the scene and interviewing the pt and/or bystanders.


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## traumateam1 (Dec 10, 2008)

MSDeltaFlt said:


> No.  During your initial trauma assessment, you need to assure you have equal bilateral breath sounds.  Kinda hard to do that without a stethescope.
> 
> Remember that your initial trauma assessment deals with your A-B-C'S.  What that means is assessing and treating life threatening conditions; i.e. a tension pneumothorax.  You do that before you move the pt.  The detailed assessments happen enroute.
> 
> ...



Thanks Delta, my lower level of training has it so that I don't use the steth during the primary survery, or initial assessment even if there is signs of a pneumo, or obvious chest injury, or some s/s of a breathing problem. They say to use it after your ABC's, because it's not necessary at the time, I guess because for the most part my treatment is limited. O2, BVM, etc.

Thanks.


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## Ridryder911 (Dec 10, 2008)

Remember, you have an upper airway & lower airway. One cannot properly assess airway (upper/lower) without assessing both. As well lower obstructions (FB in bronchus, SCW, tension pneumo) should be addressed and tx when found. 

R/r 911


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## marineman (Dec 10, 2008)

I hate to go against two who are higher trained than me but I'd have to argue that your initial ABC assessment to me is are they breathing and is the tidal volume adequate for oxygenation. I was never taught to listen to lung sounds during that stage as knowing if they have wheezing or a pneumo doesn't do much for me until I know if they have a pulse or not. The way we were taught we listen after covering the head and neck in the rapid trauma assessment. If I find a pneumo at that time I would put the rest of the assessment on hold while I got out the big needle but I don't agree with treating that prior to knowing if they have a pulse or not.

I'm not saying I'm 100% correct and most of my thoughts are "because that's what we were taught" so I'm open to different views and willing to listen to other lines of reasoning.


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## TomB (Dec 10, 2008)

It's hard to imagine a "massive" bleed hidden by clothing. Either the MOI would have penetrated (giggedy) the clothing, or the blood would soak through. In the grand scheme of things, when you consider all the time intervals involved (injury to 9-1-1 call, call processing time, reaction time, wheels up to wheels down, wheels down to patient's side), the time taken to assess breath sounds is negligible (and worth it). If there's an obvious threat to life (like an arterial bleed) then by all means, target your therapy accordingly!


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## FFMedic1911 (Dec 10, 2008)

For the short and sweet answer,do it the way you were taught.


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## MSDeltaFlt (Dec 10, 2008)

marineman said:


> I hate to go against two who are higher trained than me but I'd have to argue that your initial ABC assessment to me is are they breathing and is the tidal volume adequate for oxygenation. I was never taught to listen to lung sounds during that stage as knowing if they have wheezing or a pneumo doesn't do much for me until I know if they have a pulse or not. The way we were taught we listen after covering the head and neck in the rapid trauma assessment. If I find a pneumo at that time I would put the rest of the assessment on hold while I got out the big needle but I don't agree with treating that prior to knowing if they have a pulse or not.
> 
> I'm not saying I'm 100% correct and most of my thoughts are "because that's what we were taught" so I'm open to different views and willing to listen to other lines of reasoning.



First off, we're splitting hairs on the alphabet.  If you show up on scene and they're screaming in pain, they have an airway, are breathing, and have a pulse.  So let's not get off topic.

You're not listening for quality of breath sounds (wheezes, rales, rhonchi... yadda).  You're listening for *presence* of breath sounds.  As in whether they have breath sounds or they are lacking breath sounds.  Not having any breath sounds is an immediate life threat.  And the only way you can determine if they have them or not is in the use of a stethescope.  

As I stated earlier, tracheal deviation is a *late* sign.  Absence of breath sounds on a possible pneumo would be one the early signs that you incorporate with the other signs to come to the field dx of pneumo: SOB, MOI, flail segment, decreased chest excursion on effected side, crepitus, subq air along with tachycardia, tachypnea, ALOC, hypoxia... you get my point.  Determination of a poss pneumo is sometimes easier said than done.  So, in order to accurately dx and prevent a sentinel event (causing a pneumo where you didn't have one before), you will need *all of the available information and need it quickly*.

Tom's right.  Assessing for presence of breath sounds really doesn't take that long in the first place.

The assessment for *quality* of breath sounds is done in your secondary survey or detailed/on going assessment during your diesel bolus *to* the trauma center.


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## marineman (Dec 10, 2008)

I can understand your reasoning the way you put it in that post. In your initial assessment then do you still do the "look, listen, feel" and then listen or do you listen in place of the L,L,F? Also for rapid trauma assessment we were taught to listen in 4 areas. When doing it listening for presence of sounds for your initial assessment how many do you listen to? Is 2 enough just to hear that sounds are present bilaterally or would you want to listen in 4 or even 6 to ensure that the entire lung is equal. Again all of that might be splitting fine hairs as the time difference in 2 and 4 areas is what 5 to 10 seconds, just want to better understand exactly why I'm doing a certain method.


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## MSDeltaFlt (Dec 10, 2008)

As far as the "L-L-F", I would have to say it should be simultaneous.  I say that because we are taught that the proper way of assessing anything hollow (chest or abd) is in this order: inspection, auscultation, palpation, percussion.

Percussion on a chest with poss pneumo will sound hyper-resonant; tympanic (sounding like a tympany drum).  Which is one of the other signs.  Doing this properly takes a quiet or low volume environment... like you're going to be able to have that on scene, so I wouldn't worry about that necessarily.

As far as *where*, yes, listen in 4.  You can have a significant pneumo in the lower lobes without effecting the upper.  Because if the lower half of one lung is dropped because of tension pneumo, then that is a 25%-50% pneumothorax.  Which is, by definition, significant, and will more than likely be associated with the other clinical manifestations.


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## marineman (Dec 10, 2008)

MSDeltaFlt said:


> Yes, listen in 4.  You can have a significant pneumo in the lower lobes without effecting the upper.  Because if the lower half of one lung is dropped because of tension pneumo, then that is a 20-25% pneumothorax.  Which is, by definition, significant, and will more than likely be associated with the other clinical manifestations.



My patients will appreciate your explanation as I'm finally learning the why's of our first priority on scene. Maybe more fine hairs but how about look listen feel then ausciltate or ausciltate in place of l,l,f?


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## MSDeltaFlt (Dec 10, 2008)

marineman said:


> My patients will appreciate your explanation as I'm finally learning the why's of our first priority on scene. Maybe more fine hairs but how about look listen feel then ausciltate or ausciltate in place of l,l,f?



I think I was editing while you posted.  Sorry for any confusion.


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## AlaskaEMT (Dec 10, 2008)

I would not auscultate breath sounds during the initial assessment, I would simply ensure ventilation and administer oxygen if labored.  

I will be reaching my head-to-toe assessment in 20 seconds and will auscultate then.


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## BLSBoy (Dec 11, 2008)

AlaskaEMT said:


> I would not auscultate breath sounds during the initial assessment, I would simply ensure ventilation and administer oxygen if labored.
> 
> I will be reaching my head-to-toe assessment in 20 seconds and will auscultate then.



Then you are wrong. If you don't control pneumo/tension pneumo, you fail. In the classroom, and at life.


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## AlaskaEMT (Dec 11, 2008)

BLSBoy said:


> Then you are wrong. If you don't control pneumo/tension pneumo, you fail. In the classroom, and at life.




Actually, I'm right.  Vol II (the assessment volume) of the newest Brady paramedic books makes absolutely no mention of auscultation of lung sounds during the initial assessment, only to recognize inadequate breathing and if so, enter a rapid trauma assessment (which DOES involve auscultation) to correct such problems before moving on.

Auscultating every patient's chest during the initial assessment, regardless of breathing adequacy, not only wastes time but is blatantly wrong.

Don't be unnecessarily rude to people on a forum just because you're anonymous.


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## BLSBoy (Dec 12, 2008)

AlaskaEMT said:


> Actually, I'm right.  Vol II (the assessment volume) of the newest Brady paramedic books makes absolutely no mention of auscultation of lung sounds during the initial assessment, only to recognize inadequate breathing and if so, enter a rapid trauma assessment (which DOES involve auscultation) to correct such problems before moving on.
> 
> Auscultating every patient's chest during the initial assessment, regardless of breathing adequacy, not only wastes time but is blatantly wrong.
> 
> Don't be unnecessarily rude to people on a forum just because you're anonymous.



I'm not getting into a pissing contest with you over this. There is internet porn that I can go look at instead. I will leave you with this. If you wanna not take the extra 12 or so seconds to listen to lung sounds on a trauma pt, be my guest. If they are a trauma patient, there has been significant enough forces put on the body that not just the chief complaint area has been injured. 

But hey, you are in Alaska, far enough away from me that I won't have to worry about you treating me if I get hurt. 

And I won't be "unnecessarily rude" if you wont be unnecessarily lazy.


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## AlaskaEMT (Dec 12, 2008)

It has nothing to do with laziness, it has to do with what's correct and what's incorrect.

Feel free to back up your theories with actual references... 

Until then, Paramedic Care: Principles & Practice Vol II > BLSBoy.


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## huey28 (Dec 12, 2008)

BLSBoy said:


> Then you are wrong. If you don't control pneumo/tension pneumo, you fail. In the classroom, and at life.




ding ding ding


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## Ridryder911 (Dec 12, 2008)

AlaskaEMT said:


> It has nothing to do with laziness, it has to do with what's correct and what's incorrect.
> 
> Feel free to back up your theories with actual references...
> 
> Until then, Paramedic Care: Principles & Practice Vol II > BLSBoy.



Be careful quoting textbooks, as they are always making modifications. As well, they are out of date by the time they hit publishing. It takes about three years to be published. 

Now, if you really want proof consider looking up literature such as Journal of Trauma, Chest and Lung, prehospital care, etc...


R/r 911


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## TomB (Dec 12, 2008)

According to the PHTLS texbook (Sixth Edition):

"In the patient with abnormal ventilation, the prehospital care provider exposes, observes, and palpates the chest rapidly. The provider auscultates the lungs to identify abnormal, diminished, or absent breath sounds. Injuries that may impede ventilation include tension pneumothorax, spinal cord injuries, and traumatic brain injuries. These injuries should be identified during the primary survey and require that ventilatory support be initiated at once." - p.96

So auscultation of the chest is encouraged during the primary survey when you have identified an abnormality in the patients ventilatory status.


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## MSDeltaFlt (Dec 12, 2008)

MSDeltaFlt said:


> http://www.nremt.org/EMTServices/exam_coord_man.asp?secID=1#ASkillSheets
> 
> The above link will offer practical check sheets on NR.  Do what they say do.



Alaska, what your book may or may not say is mute when referenced against what the testing agency (National Registry) is wanting.  I posted the above link for a reason.  It says to assess breathing.  It does not say "auscultate".  It does not say "don't auscultate".  The below is a copy/paste from the above link.

Breathing
-*Assess breathing *(1 point)
-Assures adequate ventilation (1 point) 4
-Initiates appropriate oxygen therapy (1 point)
-*Manages any injury which may compromise breathing/ventilation *(1 point)

How can you adequately manage any injury which may compromise breathing/ventilation (i.e. tension pneumo) without listening to the lungs in the first place?

Saying a blanket statement of what you will or what you will not do in a given situation where the rules give you options might not be the wisest thing to say.  Loosely translated, never say never.  Never say always.  What that means is, if your trauma pt on the NR check off has a pneumo and you don't assess breathing and manage properly during your primary survey, then you will have to retest that station.  That is a critical criteria.

Since we are all nationally registered emergency medical technicians, I'm less worried about what the books say and more worried about what the NR says.


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## MOflightmedic (Dec 12, 2008)

When it comes to testing, you need to make sure you jump through the hoops they are setting out for you.  If they say no breath sounds in the primary, then that's what I'd give them--or vise versa.

Real world;  I ALWAYS listen to breath sounds on every patient--even a sprained ankle.  Listening to breath sounds on every patient is a good practice to establish.  Make it routine and it will become a habit.  It will also help your lung sound assessment skills.  You have to frequently listen to lung sounds to get good at distinguishing between them.

Personally, I REALLY like to assess anything that can "kill ya" and I like to do it early in my assessment.  As we know, a tension pneumo can be fatal and it's also a condition that we can treat.  

Absent or diminished breath sounds, in my opinion, is the most important clinical finding when suspecting a pneumothorax.  Granted, It's only one piece of the "puzzle" in a differential diagnosis but I would argue it's the biggest piece.  Naturally, other signs, symptoms, and factors would be taken into consideration, but lung sounds don't lie.

Every ALS clinician should make it a priority to develope strong lung sound assessment skills.

Good luck with your test!


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## AlaskaEMT (Dec 14, 2008)

TomB said:


> According to the PHTLS texbook (Sixth Edition):
> 
> "In the patient with abnormal ventilation, the prehospital care provider exposes, observes, and palpates the chest rapidly. The provider auscultates the lungs to identify abnormal, diminished, or absent breath sounds. Injuries that may impede ventilation include tension pneumothorax, spinal cord injuries, and traumatic brain injuries. These injuries should be identified during the primary survey and require that ventilatory support be initiated at once." - p.96
> 
> So auscultation of the chest is encouraged during the primary survey when you have identified an abnormality in the patients ventilatory status.



Ding ding ding.

Rid: Agreed.  I've heard as much as 5 years old by publication.  Either way, I was sourcing what I had.

Thanks Delta.  There is definitely room to interpret "Assess breathing".


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## akflightmedic (Dec 14, 2008)

It is MOOT not MUTE....

It is REGARDLESS, not IRREGARDLESS...

Sigh, pet peeves, my bad


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